Request for Physical Exam Simulated Patients (PESPs) for Use in Ultrasound Education Events

Request for Physical Exam Simulated Patients (PESPs) for Use in Ultrasound Education Events
Please submit your request 4-6 weeks in advance of your event.

We will review your request and get back to you within a week with the next steps in the planning process.

We look forward to working with you!
Name

First NameLast Name
Supervising Faculty

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School/Department/Organization
Course Name
In a few sentences, please state the aim of your event
Location
Will food/water be provided for the PESPs?
Will parking be provided?
Schedule
Desired Date(s)
Alternative Date(s)
Hours

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Event Logistics
Event Format (check all that apply)

Other
How many stations?
How many facilitators will be present?
What anatomical areas will be scanned?
What is the total scan time per learner?
Are there breaks built into the schedule?
Please describe breaks

Equipment and Supplies (check all that apply)

Learner Details
How many learners will participate?
Learner Affiliation (check all that apply)

Other
Who are the external learners?
Who are the learners? (Check all that apply)

Other
Physical Exam Simulated Patient (PESP) Details

SP Demographics/Recruitment Guidelines
Acceptable Age Range
Height range
Proportional Weight
Physical Limitations (e.g., incompatible previous surgeries, scars or piercings)
Funding
How will this activity be funded?
Note: At this time, there is no charge for events that serve BCM learners and trainees.
Administrator for billing
Payment Method (e.g., BCM Cost Center, Check, PO#, Credit Card)
Note: Payment is not processed at the time of request.
Please provide any additional details and attach files if applicable.
Files

Cancelof
Should be Empty:

Schedule