CLCR equest Form2011

							VCU Clinical Learning Center – CLC Activity Request Form
Completing this form initiates the planning process for your planned activity. We look forward to working closely with you to assure a
successful and rewarding experience. Feel free to contact the CLC at 828-3991 if you have questions.

First Name:

Last Name:

Today’s Date: 8/31/2012

Course / Organization:

Request Date / Time

  Activity      Time Range           Faculty to Attend /email     # Students      Room Preference     Brief Activity Description
   Date                                                                           2009, 2013, 2017,
                                                                                        2023




        If activity is the same, but dates repeat, please list dates down Activity Date column


Additional Info:

Simulations Please specify simulation/s to be run, number of stations, and time periods.

Equipment Needed & How Many (IV pumps, foley manikins, etc)

Staffing Needs:
How many CLC staff at each station/room?
What period of time do you request CLC staff assistance to run simulators/assist with simulations?

Comments


We look forward to working with you to make your session a great success!