Scheduling Request Form | Clinical Skills Center

Stony Brook CSC Event Request Form

* ALL FIELDS ARE REQUIRED *

Contact Information

Please enter the name of the person who should be contacted with questions regarding this proposal. This person may be different than the primary faculty/instructor. The contact will receive a copy of the project proposal after it has been submitted.

Contact Name

Contact Email

Client Information

Primary Faculty/Instructor Name

Primary Faculty/Instructor Email

Additional Faculty/Instructors/Staff

Event Information

Type of Activity (select all that apply)

Standardized Patient (SP)
Simulation (Manikin ONLY)
Simulation (Manikin & SP)
Skills (Procedures and Task training)
Ultrasound
In-Situ (Remote location, not in CSC)
Healthcare Training (BLS, PALS, etc.)

Event Title

Event Summary
Please provide a brief summary of the event details. The more information we know about the event will help us in the proper scheduling and event setup. Examples include overall event goals, equipment needed, AV needs, and any special needs for SP demographics or physical examination. If you have selected an Ultrasound Activity, please note that you must indicate what parts of the body will be scanned or your activity cannot be scheduled.

Case Development
Only select "Existing" if the case has been previously performed in the CSC

New
Existing

Learner Type (select all that apply)

Student
Resident/Fellow
Attending
Other

Other Learner Type:

Number of Learners

Project Schedule and Resources

The CSC completes its scheduling and assigns rooms based on the activity requested, number of participants and availability of rooms based on utilization. We ask individual departments to refrain from requesting specific rooms so that the CSC can meet the needs of as many programs as possible.

Preferred Dates

Preferred Times

Alternate Dates

Alternate Times

Additional Notes