Academics - Physician Assistant - Medical Simulation Lab Reservation Request

Date Room(s) Needed*

MonthDayYear
Is this a standalone event or recurring?

StandaloneRecurring
Please list the dates you're requesting.*
Setup Time*

Hour Minutes

AM/PM Option
Start Time*

Hour Minutes

AM/PM Option
End Time*

Hour Minutes

AM/PM Option
Clean-up Time*

Hour Minutes

AM/PM Option
Number of Students Expected*
Requesting Use of Simulation Room or Equipment*

RoomEquipment
Requesting Use of Simulation Room and/or Equipment*

RoomEquipment
Select Room(s)*

HH14 Exam rooms 1-6HH14 Simulation Rooms 1-2 and Control RoomHH203 Beds 1-12HH203 Simulation Room 3 and Control Room
Will you need a control room operator present?*

YesNo
Select Equipment*

Infant 1Infant 2Nursing Anne SIMPediatric 1Pediatric 2SIM JuniorSIM Man Essential/3GSIM MomSIM NewBABG Arm(s)Abdominal Trainer 1Abdominal Trainer 2Birthing SimulatorCaesarean Section TrainerCentral line InjectionFemale Pelvic TrainerFoley Catheter Trainer 1Foley Catheter Trainer 2Intubation torso 1Intubation torso 2IV Arm(s)Knee InjectionLumbar Puncture TrainerMale Pelvic TrainerOpthalmo SIMOTO SIMParacentesis TrainerRectal TrainerShoulder InjectionSonoSIM
Please Select Your Organization*

SEU DepartmentOutside Agency
SEU Department Name*
Agency Name*
Agency Supervisor's Name*

First NameLast Name
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requester's Name*

First NameLast Name
Office Phone Number*
Format: (000) 000-0000.
Cell Phone Number*
Format: (000) 000-0000.
Email*
Names of Instructors/Assisting Instructors Using Facility*
Has/have the instructor(s) completed the required training?*

YesNo
Please contact Dr. Nicholas Palmieri, Simulation Lab Director via email at npalmieri@steu.edu or via phone at (973) 290-4171.
Is the instructor's training certificate on file?*

YesNo
Please Upload Training Certificate*

Cancelof
Please upload signed Acknowledgment of SEU-CICE Policy and Procedure Manual*

Cancelof
Any additional notes?*
Should be Empty: