Class Reservation Form

Dear CLASS Center Clients,

To ensure the highest quality in education and scholarship, the CLASS Center is committed to standards and methods developed by the Association of Standardized Patient Educators and the Society for Simulation in Health care. To be sure projects meet these standards; all proposals must be reviewed and approved by the CLASS Center Projects Committee. We are eager to support new projects, and if a project needs further development to meet standards, the Center will assign one of our educators to work directly with you. However, please understand that the Center schedule is very busy, so we cannot guarantee that we can schedule your event within your ideal time frame.

Please read the CLASS Center Policies before submitting this form.

Please note: Submission of this form DOES NOT guarantee room availability. You will receive a confirmation email once the reservation has been finalized.

Thank you,

CLASS Center Faculty and Staff

George Washington University School of Medicine and Health Sciences Clinical Learning and Simulation Skills Center

Requestor Information

* First Name
* Last Name
* Department (or name of non-GW organization)
* Email Address
* Phone Number
Person responsible for ensuring CLASS Center policies and procedures will be followed (may be different from person completing this form:
* Name: * Email:
* Level of Learners Check all that apply
AI
Clerkship
MS 1
MS 2
MS 3
MS 4
RATS,FATS,ARTS
Residents
Nurse Practioners
Physical Therapy Students
Physician Assistants
Hospital Employees
GW Undergrad Students
Other Please Specify    
* Course
* Name of Event
* Event Date(s) Requested * Event Time(s) Requested
1.
2.
3.
4.
5.
* What type of event is this? Check all that apply
Standardized/Simulated Patient (SP) Learn more
Simulation Learn more
Neither, we just need to reserve rooms
* Estimated Number of Learners
* Amount of Time Learners will spend in the SP/Simulation event
* Would you like to publish this project?
* Is this event part of a grant funded project?
* Would you like your event to be recorded?

Rooms Requested

* Exam Rooms? Learn more
How Many?
* Simulation Rooms? Learn more
How Many?
* Conference Rooms? Learn more
How Many?
Preference on location of rooms

Project Information

* Please give a detailed description of your proposed project?
* What are the educational objectives for this project?
* How will you determine that your objectives are met?

CLASS Center Acknowledgement Agreement

I agree that if I plan to present information /data about this project at meetings or publish information/data about this project in educational journals, I must notify the CLASS Center via email to class@gwu.edu of my plans in writing at least 2 weeks in advance of the meeting or manuscript due date. Someone from the center will instruct me whether to include the acknowledgement, "From the George Washington University Clinical Learning and Simulation Skills Center, Washington, DC" in the presentation/publication. I also agree to include the CLASS Center faculty and/or educators as presenters or authors if they collaborate in the design of this project.

I have read the CLASS Center Rules and agree to them.

If there are any changes to any of the information submitted, I will email the CLASS Center at class@gwu.edu and let them know.

I understand that submitting this form does not guarantee reservation until I receive a confirmation email.
* Please type your name here to accept the CLASS Center Acknowledgment Agreement