HSC Classroom Space and Simulation Request Form

Please complete a separate form for each Healthcare Simulation Center Classroom Space and Simulation Request.

Course requests must be submitted in advance by the designated deadline dates posted on the G drive. Late requests will not be honored after the deadline except for emergency reasons (see emergency request form).

Date Requested Date Requested * / MM / DD YYYY
Time Requested Time Requested * : HH MM AM/PM
Select from the following options below *

Select from the following options below Request HSC Tour Conference Room HSC Simulation lab Cafe seating Healthcare Simulation Center and flexspace classrooms Flexspace simulation/classroom
Discuss with Center

Discuss with Center Yes No
Number of participation
Number of Flexspace classrooms

For Flexspace simulation/classrooms request only
Catering Service Required

Catering Service Required Yes No

For conference room request only
Number of simulations

For HSC Simulation lab request only
Check the box/boxes below that apply

Check the box/boxes below that apply Will provide learning materials including simulation scenarios, scripts etc. Will provide consumable supplies (IVs, dressings etc.) Will need consumable supplies provided by HSC Request individualized curriculum development based on agency needs. Request individualized simulation scenario development based on agency needs. Request individualized training program development based on agency needs. Request collaboration on grant project. Other Other
Describe the training that is being requested
Request telephone call to discuss
Name of agency *
Name of contact person Name of contact person * First Last
Contact number Contact number * - ### - ### ####