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SimLab Course Request Form
Complete all fields to request the use of the PSI space and resources for your course. After completing the form, please email
PSI.SIUH@gmail.com
to say you have made a request. Thank you.
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* Indicates required question
Department
*
Anesthesiology
Burn
Dental
Emergency Medicine
Internal Medicine
Nursing
Ob/Gyn
Pediatrics
Podiatry
Psychiatry
Radiology
Rehabilitation Medicine
Surgery
Neonatal
Speech Pathology
Other:
Required
What is the status of your course?
*
New class
Class renewal
Simulation Instructor
*
List all instructors teaching this course.
Your answer
Contact Person
*
Who is the liaison for the course?
Your answer
Phone Number
*
What is the best phone number to reach you?
Your answer
E-mail Address
*
What is the best e-mail address to reach you?
Your answer
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