Preliminary Course Request Form

Course Title*
Course Director*
Contact Person*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Department*
Funding Source*
Learners*
Describe your course*
How did you establish the need for this course?*
Learning Objectives*
Please list any metrics or measurements that you plan to use to determine the effectiveness of the course you are proposing to develop
Simulation Modalities Requested*

Patient SimulatorBiohazardous TissueStandardized ParticipantTask TrainerAugmented RealityUncertain
Number of Learners*
Number of Instructors*
List the Instructors*

FacultyResidents/FellowsStudentsSimulation Center StaffOther
Target Month for the Course*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Learners*

Medical StudentsResidentsHealth Profession StudentsFellowsPhysiciansAllied Health ProfessionalsNursesOther
Course Duration*

2 hours3 Hours4 HoursFull DayOther
Should be Empty: