ATSSL Booking Request Form
This form should take 5-10 minutes to complete.
Event Name:
*
Which of the following best describes this event?
*
Skills Training
Simulation (with Mannikins or Actors)
Simulation Facilitator Training (FACETS)
Externally Developed Course (ATLS, ACLS, EDE etc)
Anatomy Review
Industry Sponsored Event
ATSSL Approved Research (if not approved: visit https://cumming.ucalgary.ca/atssl/research)
Other
Requester Name:
*
First Name
Last Name
Requester Email:
*
example@example.com
Requester Phone Number:
Please enter a valid phone number.
Are you the Educational Lead for this Event?
*
Yes
No
Educational Lead Name:
First Name
Last Name
Educational Lead Email:
example@example.com
What is the University of Calgary IRISS REB Submission # for this project?
Are you the principal investigator (PI) for this project?
Yes
No
Principal investigator name:
First Name
Last Name
Principal investigator email:
example@example.com
Please include the email of any additional contact you would like included in correspondence about this event:
example@example.com
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Next
What is your primary affiliation?
*
University of Calgary (UME, PGME, CME)
Alberta Health Services
Industry Representative
External (Schools, Medical Clinics)
Other
Which UCalgary department do you represent?
*
Postgraduate Medical Education (PGME)
Undergraduate Medical Education (UME)
Continuing Medical Education (CME)
Postgraduate Education
Undergraduate Education
Other
Which UCalgary program do you represent?
Which department and/or unit do you represent?
Which company do you represent?
Which organization do you represent?
Which ATSSL Resource are you interested in booking?
*
Facilities (ATSSL lab and/or classroom space)
Simulation Equipment (For use outside of ATSSL)
Event Overview/Summary:
*
Please list the learning objectives:
Please select all CanMEDS competencies that will be assessed:
Professional
Communicator
Collaborator
Leader
Health Advocate
Scholar
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Which specific ATSSL space are you looking to reserve?
*
Lab Space - Surgical Skills Laboratory (HRIC BA01)
Lab Space - Clinical Simulation Laboratory (HSC G820)
Classroom Space - HRIC BA04 and/or HRIC BA06 Only
Unsure
Do you require any equipment?
*
Yes
No
Please list what equipment and number of each you will require:
*
What consumables and what number of each would you like to request?
Do you require cadaveric specimens? (by answering YES, I acknowledge and affirm that the learners for who will be using this educational material and engaging in skill practice activities are entirely within their legal scope of practice).
Yes
No
Which region(s) of the body are required?
Which procedure will be performed?
What activity will you be performing?
What quantity of specimens do you require?
(number)
Will this event be catered?
Yes
No
Which of the following best describes the session you would like to book ATSSL resources/services for?
*
Single Day Event
Multi-Day Event
How many sessions would you like to book?
2
3
4
5
Preferred Start Date:
*
/
Year
/
Month
Day
Date
Preferred End Date:
/
Year
/
Month
Day
Date
Preferred Start Time:
*
Hour Minutes
AM
PM
AM/PM Option
Preferred End Time:
Hour Minutes
AM
PM
AM/PM Option
Preferred Start Date #2:
/
Year
/
Month
Day
Date
Preferred start time for Date #2:
Hour Minutes
AM
PM
AM/PM Option
Preferred end time for Date #2:
Hour Minutes
AM
PM
AM/PM Option
Preferred Start Date #3:
/
Year
/
Month
Day
Date
Preferred start time for Date #3:
Hour Minutes
AM
PM
AM/PM Option
Preferred end time for Date #3:
Hour Minutes
AM
PM
AM/PM Option
Preferred Start Date #4:
/
Year
/
Month
Day
Date
Preferred start time for Date #4:
Hour Minutes
AM
PM
AM/PM Option
Preferred end time for Date #4:
Hour Minutes
AM
PM
AM/PM Option
Preferred Start Date #5:
/
Year
/
Month
Day
Date
Preferred start time for Date #5:
Hour Minutes
AM
PM
AM/PM Option
Preferred end time for Date #5:
Hour Minutes
AM
PM
AM/PM Option
Preferred pickup date:
*
/
Month
/
Day
Year
Date
Preferred return date:
*
/
Month
/
Day
Year
Date
How many learners are expected to attend this event?
*
How many facilitators are expected to attend this event?
*
Will you require an estimate for the fees associated with this request?
Yes
No
Please indicate which of the following will be used for covering any costs incurred by your request?
University of Calgary Account
AHS Account
Cheque
EFT
No Anticipated Cost
Contact Email for invoice processing.
Please upload any relevant documents.
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