Thank you for your scheduling request at the Penn Medicine Clinical Simulation Center. In order to best serve your group please answer the questions below to the best of your ability, completing this form at least four weeks prior to your event if this is a novel course.

To ensure a prompt response to your request, please email to let us know you have requested a training session. This email can also be used to address any questions you might have.

DO NOT use this form to register for ACLS, PALS, BLS or NRP courses. That MUST be done through Knowledge Link.

* 1. Proposed Course Title:

* 2. Proposed Course Date(s):

* 3. Proposed Course Time(s):

* 4. Sponsoring Department:

* 5. Faculty/Instructors to Provide Training:

* 6. Your Name and Contact Information:

* 7. Contact in Event of Scheduling Issue (if same as above please indicate this):

* 8. Number of Students to Attend Session:

* 9. Type of Learner/Participant:

* 10. Has any type of needs assessment been performed at this time?

* 11. Session Learning Objectives:

* 12. Please list the metrics you will monitor to determine the effectiveness of this session. (Reduced length of stay, Infection rate, etc ):

* 13. Which of the Imperatives in the FY15 Penn Medicine Blueprint for Quality and Patient Safety will this training address (may be more than one).

* 14. Location of Training: