SCHEDULING FORM FOR SIMULATION LAB-CMHS /Remera, Rwamagana and Huye Campuses (simulationcmhs@gmail.com)
ONCE YOU BOOK FOR DEMONSTRATION INFORM STUDENTS TO BOOK FOR SELF PRACTICE BEFORE OSCE
NB:
1.THE BAGS ARE NOT ALLOWED AT SIMULATION LAB AREA
2. LAB COAT/CLINICAL UNIFORM IS MANDATORY FOR ANY USER OF SIM LAB.
Date of booking *
MM
/
DD
/
YYYY
Module Name *
Your answer
Module leader *
Your answer
ACADEMIC TITLE OF MODULE LEADER *
Required
SCHOOL/DIRECTORATE/Institution *
Required
DEPARTMENT/DIRECTORATE/ Unit *
Your answer
STUDENT YEAR *
Required
TYPE OF ACTIVITY (Eg. DEMONSTRATION) *
NAME OF ACTIVITY( Eg. Immediate care for new born) *
Your answer
DATE OF ACTIVITY *
MM
/
DD
/
YYYY
TIME OF STARTING ACTIVITY (Eg. 8:00 AM) *
Time
:
TIME OF ENDING ACTIVITY (Eg. 5:00) *
Time
:
EQUIPMENT AND SUPPLIES (CHEMICAL PRODUCTS) REQUIRED FOR ACTIVITY *
Your answer
NUMBER OF STUDENTS/TRAINEES WHO WILL BE PARTICIPATING IN THE ACTIVITY *
Your answer
NUMBER OF ACADEMIC STAFF/ FACILITATORS WHO WILL BE PARTICIPATING IN THE ACTIVITY *
Your answer
NUMBER OF SIMULATION STAFF NEEDED FOR THE ACTIVITY *
Your answer
LEARNING GOAL FOR THE ACTIVITY *
Your answer
EQUIPMENTS, CONSUMABLES OR ACTIVITIES MAY CONDUCT TO ANY HAZARDS *
IF YES WHAT ARE THEY?HAZARDS
Your answer
IF YES WHAT ARE PRECAUTIONS?
Your answer
Campus *
Required
I AGREE TO ABIDE BY THE SIMULATION LAB'S POLICIES AND REGULATIONS *
COMMENT OR SUGGESTION
Your answer
REQUESTOR' S CONTACT (email and mobile phone) you shall have notification email after submission in 3 working hours *
Your answer
THANK YOU VERY MUCH
Your answer
NUMBER OF ROOM REQUIRED *
Your answer
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