Activity Request

First Name*

Last Name*

Email*

Phone Number*

Department*

First Name*

Job Title*

Phone Number* (cell preferred)

Do you have a scenario or script prepared for this event

Will you need assistance creating or finalizing the scenario for this event?*

Will you be needing simulation or audio/visual equipment for your event?*

“Standardized Patient Event Details*

How many SP will be needed for your event?*

Event Location* (please include room number)

Proposed Event Date*

Requested SP Report Time*

Anticipated SP Dismissal Time*

How many participants do you anticipate?*

What best describes this Event’s Learners?*

Is there any other information you would like to share?*

Event Requestors can expect follow up communication from our SP Coordinator within 72 hours of submission. We look forward to supporting you.

New SP Event Proposal