Rural Simulation Center Request Form

Name of Person and agency: *

Time Requested *

Date Requested

mm/dd/yyyy

Number of persons scheduled to attend *

Simulation Educator responsible for the session *

Use this space to communicate additional information about your simulation request.

Please enter the e-mail addresses of educators you would like to receive course reminder information

Please indicate the mannequin(s) you plan to use for this educational session *

I would like to request a standardized patient volunteer *

		Yes
		No

Please describe your standardized patient request.

*Please note, requests for live actors should be sent at least 30 days before the event.

Please list equipment needs from our standard list. *

Detailed List of Other Equipment Requested if needed.

Primary Contact e-mail *

Please attach your scenario template here. Or, if the templates are on file, please attach your educational plan and timeline. Completed scenario templates are due no later than 2 weeks prior to your simulation event.

Please attach any accompanying files (x-rays, labs, etc.) here. Your file size is limited to 200 kb

Additional files. Your filesize is limited to 200 kb

* = Input is required