Education Request Form Question Title * 1. Requestor Name Question Title * 2. Requestor Program/Facility Question Title * 3. Date of Request Date Date Question Title * 4. Course Topic Requested Question Title * 5. What service(s) are you requesting? Select all that apply. Research and creation of course material (for e-learning, in-person, or webinar) Design, update, or revision of course material provided by requestor Course facilitation: live webinar Course facilitation: in-person Question Title * 6. In what format would you like this course delivered? E-learning Live Webinar In-Person Facilitation Question Title * 7. Will you be providing course materials/resources or do you need the content developed by the L&D team? I will be providing course materials/support documentation I will not be providing course materials/support documentation Comments: Question Title * 8. To your knowledge, do any courses already exist on our platform related to this topic? No/unsure Yes If you answered Yes, please explain how your request differs from the existing course(s)? Question Title * 9. What is the desired length of this course? Less than 15 minutes 15-30 minutes 30-45 minutes 46-60 minutes 1-2 hours 2-4 hours 4-6 hours 6-8 hours Multi-day course Additional details: Question Title * 10. Audience for requested course. Select all that apply. All staff levels PCA/HHA CNA LPN RN NP/MD Houskeeping Dietary Administration Leadership Therapy Care Management Other (please specify) Question Title * 11. Will this course be appropriate for all roles identified above within entire ArchCare System? Yes No If you answered No, please explain why not. Question Title * 12. Requested delivery date:(Please note that while we will try our best to meet your requested delivery date, turnaround times for approved requests depend on amount of development and design required, available resources, length of course, number of existing open requests, and other factors.) Date Date Question Title * 13. Additional Comments/Information: Submit Request