ONLINE EVENT REGISTRATION
Make sure to submit this form at least one month before event starting date
* Required
KSU'S CLINICAL SKILLS AND SIMULATION CENTER
Title of suggested event
*
Your answer
Write 3 to 5 learning objectives for you Event
*
Your answer
Write a brief description for your event
*
Your answer
Target Audience
*
Your answer
Length of the Event
*
Your answer
Tentative dates
*
MM
/
DD
/
YYYY
Number of participants( Minimum - Maximum)
*
Your answer
Type of Learners
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Choose
KSU Staff
Non-KSU staff
Both
Speciality
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Choose
Surgeon
Non Surgeon Physician
Surgical Resident
Resident from other disciplines
Nurses
Allied Health Professionals
Medical Students
Other Students
Others
Logistics, Medical Equipments are needed:
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YES
NO
If yes, Please specify:
*
Your answer
Number of training rooms :
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Your answer
Number of Lecture Rooms
Your answer
Simulation Modality (its) is\are needed
*
High Fidelty
Medium Fidelity
Low Fidelity
Task Trainer
Virtual Reality
Standardized Patient
Hybrid Simulation
Support Services:
*
Catering
CME's
Stationary
A\V Aids
Support Staff (Secretaries, Porters...)
Other:
If others, please specify
*
Your answer
Requester Initials:
Your answer
Date of submission:
MM
/
DD
/
YYYY
Email address
*
Your answer
Mobile Number
Your answer
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