Learning and
Assessment Center




Learning and
Assessment Center

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Request to Schedule an Event with the LAC:

Please fill out the following form completely.

Complete a new form for each additional Event that you wish to Schedule

Institution Name
Course Number
Please indicate if this is a new or repeat event:

Requested date(s) of the Event: (month/day(s)/ year) (If this is a multiple day event, please list all of the date(s).

Please enter your 1st choice of date(s)
2nd choice of date(s)
Time of Event:
Name:
Address:
Phone:
E-mail:
Brief Description of the Event
Type of Learner(s) (Example: Student- Year 2; PGY I, II Residents; Health Care Professionals)
Total number of Learners to be involved
Will you require Standardized Patients?
Will you require any Nurses (RN, LPN)?
Will you require Simulation Equipment?
If yes, what kind?
Will you need Case Scenarios Developed?
Will you require Digital Video recording?

Reminder: this is a request for the dates of your event. Your confirmation of these event dates are pending.