Simulation Reservation Request

School of Nursing/Medicine Courses

Questions or Concerns: Laurie Youker, youkerl@ohsu.edu
Phone:503 494-0132
Fax: 503 494-9561

Please fill out this form and return via email 2-6 months prior to requested dates.
Please list your preferred dates so that we can best meet your needs.
Your reservation request will be reviewed and a confirmation email will be sent once all requests are reviewed (2 months prior to the start of the next school term).

First Name:

Enter your first name

Last Name:

Enter your last name

Program Name:

Course Name and #:

Position:

Phone:

E-mail Address:

Pager #:

Which Mode of communication do you prefer?:

phone

e-mail

pager

How many students do you need to schedule?:

How many students would you like in each group?:

How many groups does that produce?:

How many times would you like each group to attend simulation?:

What time would you like to schedule simulation (am/pm/both/or specific times):

What are your set clinical days for this course?:

Do you have specific dates for simulation or will any clinical day work?:

If specific, please list dates here: