Simulation Scheduling Request Form

Health Simulation Scheduling Request Form

The information contained within this document is confidential and should not be shared with anyone outside the Health Simulation Program
After submitting this form, please be on the lookout for an email from RobinBates@southalabama.edu for verifcation that your event has been scheduled.
Name*
Email*
example@example.com
Phone*
Timespan of Requested Event (e.g. 8-12, 1-5, or all day)*
Preferred Date of Event*

MonthDayYear
Date
Course Name / Number*
Anticipated Number of Learners*
Event Scenario Description*
Requested Event Location (Sim lab, skills lab, classroom; if unsure please indicate "Per Simulation")*
Learner Objective (attach any document below if needed)*
File Upload

Cancelof
Learning Objective 2 (if applicable)
Learner Objective 3 (if applicable)
Supplies provided by Course Faculty*
Supplies to be provided by Simulation (e.g. high fidelity manikin, task trainers, IV arm, airway head, gloves, gowns, etc.)*
Please indicate if standardized patients will be required for your event. If SPs are required a separate form is required to indicate details for this request Contact Miranda Powell - malexander@southalabama.edu*
ADDITIONAL INFORMATION
-It is the course faculty's responsibility to provide all event details in a timely manner.

-Simulation reserves the right to cancel an event if final details (edited case, student count, etc.) are not provided at least 2 weeks prior to the event date.
Should be Empty:

Health Simulation Scheduling Request Form