Anatomy Laboratory Request Form

Anatomy Laboratory Request Form

BSWH Temple
The Anatomy Laboratory supports educational activities, research projects, and clinical skills training for a wide range of learners.

Please complete the items in the request form at least 90 days prior to the intended date of your activity.

If you have questions about the lab or scheduling, please contact the anatomy lab at summer.tharp@bswhealth.org. Questions about the form or body donors should be directed to the Lab Director:

Contact Information
Please provide the contact information for the primary faculty/clinical member submitting the request.
Name of faculty/clinical requestor*

First NameLast Name
Primary department*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please provide information of the primary financial administrator for the activity.
Name of financial administrator*

First NameLast Name
Department*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Will a vendor/company be involved in the event?*

YesNo
What is the name of the vendor/company?
Name of primary contact for vendor/company

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com

Event Details
Name of event*
Date of event*

MonthDayYear
Date
Time range for event*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Who will provide the PPE (Personal Protective Equipment)?

BSWH anatomy labDepartment/Vendor
Additional rooms/areas needed besides the laboratory.*

Conference room (seats 30)Conference room (Seats 10)Catering area (buffet style counter)None
Please describe the surgical approach or procedure you will be practicing on the specimen/donor. Include as much detail as possible.*

Participant Information
Intended learners/participants.

Residents or FellowsAttending physiciansMedical studentsPhysical therapy studentsPhysician assistantsIndustry representativesOther
Number of residents or fellows
Number of attending physicians
Number of medical students
Number of physical therapy students
Number of physician assistants
Number of industry representatives
Number of other participants

Contact Information