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Request for the Anesthesia Simulation Center
Requests should be made at least 4 weeks prior to the planned date of your event. Approval will be sent via email. Please note that fields marked with an asterisk (*) are mandatory.
Faculty Instructor Name:*
Faculty Instructor Department:*
Phone:*
E-mail Address:*
Pager Number:
Department Contact Name:
Department Contact E-mail Address:
Describe your Availability:*
Target Audience:*
Scenario Description and Objectives:*
Requires Adult Mannequin?
No
Yes
Requires TEE Mannequin?
No
Yes
Requires Pediatric Mannequin?
No
Yes
Requires Portable Mannequin?
No
Yes
Requires Phantom?
No
Yes
Other Equipment Needs (IV arms, various airway trainers, etc.):