Request Equipment - Simulation

Request Equipment
Please submit this form at least one month before your preferred date. However, if you are on a shorter timeframe, please submit the form and we'll do our best to work with you.

For additional information about our resources, please refer to our Simulation Resource Catalog.

Please note: Equipment loans are at the discretion of the Simulation Core. Human Patient Simulators, Surgical Simulators, and other advanced trainers must be used in our facilities.
First Name
Last Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Role *
School / Department / Organization*
If you are a student group, please identify your faculty sponsor
Faculty sponsor email
example@example.com
Administrator for billing
Activity name*
Pickup date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Return date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Equipment and supplies requested*
Other details
By submitting this form*

I understand that the use of the simulation equipment and supplies is for educational purposes only.I agree to return equipment and supplies in the same working condition that I received them.I understand that if the equipment and supplies are stolen, misplaced, or damaged, I, or my department, will reimburse the amount necessary to replace or repair the equipment and supplies.
Should be Empty: