Standardized Patient Request Form (GME/BSW/EXTERNAL)

Previously Occurred*

Full Name*

Email*

Phone Number*

Job Title*

Event Name*

Faculty on Site*

Date of Activity*

Add Date Delete Date

Start Time*

End Time*

Recurring Frequency*

Event Location*

How many learners?*

Will video recording be needed?*

Recording capabilities are limited. SP Program will work with you to accommodate your needs but will not be guaranteed.

Special Requests*

If Simulation equipment is required, please refer to the Request An Activity section within the Clinical Simulation page located here.

If student numbers change this information needs to be communicated immediately to the SP Program.

Please input students name and special requests below. Provide names ONLY if a student rotation schedule is needed.

Student Last Name

First Name

Special Requests*

Add Student Remove Student

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