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
Course director new?
Yes
Facilitator 1
Facilitator 1 new?
Yes
Facilitator 2
Facilitator 2 new?
Yes
Facilitator 3
Facilitator 3 new?
Yes
Facilitator 4
Facilitator 4 new?
Yes
Facilitator 5
Facilitator 5 new?
Yes
Facilitator 6
Facilitator 6 new?
Yes
Section 3: Sponsor/Participants Information
Title of Course
Sponsor:
Who is responsible for payment 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 5: Equipment Information
Delivery Location
Individual Authorized to Pick up Equipment
Equipment Requested
Simulator(s) Requested
Simulation Support Requested
Yes
No
If Yes, Please Include Details
Sim Center Supplies Requested (List All)
Other Activity Specific Supplies Needed
Note:
If specific consumables are not available, procurement and reimbursement arrangements must be made between the MUSC
Healthcare Simulation Center and the Requesting Unit.
Special Instructions
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