Section 1: Contact Information

Full Name

Title

Email Address

Phone Number

With area code. No dashes.

Department

Alternate Contact

Alternate Email

Alternate Phone

With area code. No dashes.

FDM Billing Information

Company

Revenue/Spend Category

Fund ID

Cost Center

Function ID

Gift/Grant

Program ID

Additional Worktag

Section 2: Activity Information

Organization

College

Department

Activity Title (External)

Other (If Not Listed)

Course Director

Facilitators

Participant Type

Number of Attendees

Section 3: Sponsor/Participants Information

Title of Course

Please complete the following for this activity (required)

Number of Groups of Learners planned per Day Requested

Number of Learners per Group

Number of Hours of Instruction per Learner

Sponsor: Who is responsible for this activity?

Same as previous requestMUHACollege of MedicineCollege of NursingCollege of Health ProfessionsCollege of Dental MedicineCollege of PharmacyOther MUSC College/Department/ProgramMUSC AffiliateMUSC GrantExternalOther

MUHA

Nursing Professional DevelopmentOther

College of Medicine

Undergraduate Medical EducationDepartment/ProgramOther

College of Nursing

Department/ProgramOther

College of Health Professions

Department/ProgramOther

College of Dental Medicine

Department/ProgramOther

College of Pharmacy

Department/ProgramOther

Please List

Participants: Who are the learners for this activity?

Same as previous requestMUSC StudentsOther StudentsPhysiciansDentistsPharmacistsProfessional Nurses (RN, APN, etc.)Other Health ProfessionalsOtherCheck all that apply

Physicians

Attending/FacultyFellowsResidentsCommunity

Dentists

Attending/FacultyFellowsResidentsCommunity

Pharmacists

FacultyMUHACommunity

Professional Nurses (RN, APN, etc.)

FacultyMUHACommunity

Other Health Professionals

FacultyMUHACommunity

Please List

Section 4: Activity Schedule

Activity 1

Date

Start Time

End Time

Activity 2

Date

Start Time

End Time

Activity 3

Date

Start Time

End Time

Activity 4

Date

Start Time

End Time

Activity 5

Date

Start Time

End Time

Section 6: Rooms Requested

Please Select Room

EL200C	EL200E	EL200F
EL200G	EL203A	EL203B
EL203E	EL203F	EL203G
EL203H	EL203K	EL203L
EL203M	EL203N

Note: Every effort will be given to reserve the rooms requested; however, the MUSC Healthcare Simulation Center may substitute a comparable room if necessary due to scheduling conflicts.

Section 5: Special Instructions and/or Comments

By clicking here, I state that I have read and agree to the terms and conditions outlined in the MUSC Healthcare Simulation Policies and Guidelines (PDF) document.

Yes