Request to Schedule an Event with LAC

(You must fill out a new form for each Event you wish to schedule)

Institution/ College/ Department Name:  

Date(s) of Event: (List 3 separate, in order of preference; month/ day/ year)        

 1st  2nd 3rd

Time(s) of Event:   am    pm

Lead Contact Information:

Name:   
Address:
Phone:  Cell:
Email:

Brief Description of Project Objective / Outline of Event:  (100 words or less)

Type of Learner:
(Example:  Student -Year 2, Graduate, Professional, Health Care Provider)
Number of Learners to be Involved: Estimated Number Would like to Discuss
Number of desired Encounters per Learner: Estimated Number Would like to Discuss
Length of each Encounter: Estimated Number Would like to Discuss
Will you need Case Scenarios Developed? Estimated Number Would like to Discuss
Standardized Patient(s) Required: How many?
Simulation Equipment Required:
What kind?
Videotaping Required:

 
Michigan State University Colleges of Human Medicine, Nursing, Osteopathic Medicine, and Veterinary Medicine