Activity Request - Augusta University Interdisciplinary Simulation Center

Interdisciplinary Simulation Center Simulation Consultation Request Form

This form will help us to schedule a consultation with you and others in your program to help develop simulation activities, scenarios, faculty development, or any other simulation related questions and will help us to route your request to the most appropriate simulation team member.
Instructions:

Complete this form in its entirety, filling all applicable and required fields.

Upon submission of your consultation request you will receive a request confirmation number and email. Please feel free to email simulationcenter@augusta.edu with any questions that you may have.
Subject of consultation*
Describe the topic to be discussed
Department*
The department or organization to which this consultation pertains
Consultation type*

Simulation Activity (Event Planning)Simulation Scenario DevelopmentProcedural Skills ActivityClinical Skill Exam RoomsLectureIn-Situ SimulationOther
Requested Dates and Times for initial consultation*
Contact Information

Primary Contact (Required)
Primary Contact Name*

First NameLast Name
Primary Contact Phone Number*

Area CodePhone Number
Primary Contact Email *
example@augusta.edu
Title
Department
Note: The primary and secondary contact will receive the submission confirmation email and will be invited to consultation meeting (to be sent as an Outlook meeting request.

Interdisciplinary Simulation Center Simulation Consultation Request Form