CSEAC Standardized Patient/Exam Room Reservation Request Form

Reserved by (Full Name) *

Department *

Course *

Email *

Phone *

Event Title *

Event Start *

Event End *

Is this a reoccurring event? *

Yes

No

If yes, please list the dates and times of each event

If training Medical Students Year 1, How many?

If training Medical Students Year 2, How many?

If training Medical Students Year 3, How many?

If training Medical Students Year 4, How many?

If training Residents PGY1, How many? *

If training Residents PGY2, How many?

If training Residents PGY3, How many?

If training Residents PGY 4-7, How many?

If training graduate students, How many? *

If training/assessing faculty, How many? *

If training undergraduate students, How many? *

If training other than those above, please specify

Will you need the classroom area? *

Yes

No

Will you need the disability/hospital room/exam room 14? *

Yes

No

Please provide the number of exam rooms needed? *

Will you need standardized patients? *

Yes

No

If so, how many standardized patients are needed?

Do you need to record your event (practice session or exam)? *

Yes

No

Do you need to use the digital/av/plasma system in the classroom area? *

Yes

No

Will your department faculty be attending the session(s) (e.g., to assess, facilitate)? *

Yes

No

Please list any supplies you will be using/need? *

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