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
Please select...
MUHA
MUSC
Other/External
College
Please select...
N/A
College of Dental Medicine
College of Health Professions
College of Medicine
College of Nursing
College of Pharmacy
Department
Please select...
N/A
All Dental Medicine
All Health Professions
All Nursing
All Pharmacy
Anesthesia
Central Office
Curriculum (UME)
Emergency Medicine
Family Medicine
Internal Medicine
Obstetrics and Gynecology
Orthopaedics
Pediatrics
Radiology
Simulation Center
Surgery
Activity Title (External)
Please select...
EXT AAOMS Airway
EXT End of Life RN Consortium
EXT Kershaw Carolina Pines Nurse Orientation
THEALTH EMS
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 request
MUHA
College of Medicine
College of Nursing
College of Health Professions
College of Dental Medicine
College of Pharmacy
Other MUSC College/Department/Program
MUSC Affiliate
MUSC Grant
External
Other
MUHA
Nursing Professional Development
Other
College of Medicine
Undergraduate Medical Education
Department/Program
Other
College of Nursing
Department/Program
Other
College of Health Professions
Department/Program
Other
College of Dental Medicine
Department/Program
Other
College of Pharmacy
Department/Program
Other
Please List
Participants:
Who are the learners for this activity?
Same as previous request
MUSC Students
Other Students
Physicians
Dentists
Pharmacists
Professional Nurses (RN, APN, etc.)
Other Health Professionals
Other
Check all that apply
Physicians
Attending/Faculty
Fellows
Residents
Community
Dentists
Attending/Faculty
Fellows
Residents
Community
Pharmacists
Faculty
MUHA
Community
Professional Nurses (RN, APN, etc.)
Faculty
MUHA
Community
Other Health Professionals
Faculty
MUHA
Community
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
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