Activity Request Form

Activity Request Form - Original
Requests SHOULD BE COMPLETED 10 to 12 weeks before the beginning of the Event. Within 48 hours of recieveing this form our staff will schedule a meeting with the Faculty Lead to dicuss further logisctics of this Activity.
Today's Date

MonthDayYear
Date
Primary Activity Contact - Name*
Primary Activity Contact - E-mail*
Primary Activity Contact - Number*
Secondary Activity Contact - Name*
Secondary Activity Contact - E-mail*
Secondary Activity Contact - Number
What course is this request for? *
Activity Type?*

New ActivityRepeat Activity
Title of repeat Activity (course number, title per Syllabus and area of focus "i.e FM 502 - SP #5 Motivational Interviewing")

0/250
Type of Assessment*

Formative - ungradedSummative - graded
Please Briefly Describe the Activity *

0/250
Learning Objectives *
Preferred Simulation Center Room*

InpatientOutpatientSkills based - Task TrainerHospital WardMultipurpose RoomUnknown
Preferred Simulation Modality

High FidelityMid FidelityLow Fidelity
What type of Case?*

New CaseRepeat Case - Minor UpdatesRepeat Case - Major Revisions
Please indicate the number of Cases for this Activity
Please summarize the New Case

0/500
What Case or Cases will be used for this Activity? Please enter Patient Name associated with the case.

0/250
Please summarize anticipated MAJOR Revisions

0/500
What type of learner will be involved?

Osteopathic Medical Student (Automatic - if not DO please unclick)ResidentNursing StudentPharmacy StudentPhysical Therapy StudentOccupational Therapy StudentDentistry StudentOther
If a D.O. students please choose what cohort?

OMS 1OMS 2OMS 3
If a Nursing students please choose what cohort?

JuniorSeniorOther
If a Pharmacy students please choose what cohort?

Pharm 1Pharm 2Pharm 3
If a Physician Assistant students please choose what cohort?

PA 1PA 2
How many learners per event? *
How many Patients will the learners see per event? *
Each Activity is broken up into Events of 4 hours per event. If an Event is running both Morning and Afternoon please list AM and PM as two (2) separte Events.
How may times will this Activity occur?
Event Date One: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Two: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Three: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Four: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Five: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Six: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Seven: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Eight: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Nine: *

MonthDayYear
DateHourMinutesAM/PM Option
Event Date Ten: *

MonthDayYear
DateHourMinutesAM/PM Option
General Comments
Should be Empty:

Activity Request Form - Original