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 Indicates Required Field
 

Standardized Patient Reservation Form

 
Event / Course Name
 
Booking requested by:  
 
Faculty / Organization
 
Department
 

Contact Name

 

Mailing Address

 
Phone Number 
 
 
FAX Number
 
Email
Note: A copy of this form will be emailed to this address upon completion.
Send me this email as HTML instead of plain text.
 
Type of session
 
Requested Date/Timemm/dd/yyyy
 Calendar  
 
 
Comments/ Additional Booking Information

(you may add the  date and time of  the recurring sessions of the same type)

 
 
 Submit as HTML
 

REMINDER: Please be advised that sessions longer than three (3) hours must include a 15 minute break and sessions longer than five (5) hours must include a meal break.

 
Do you need to reserve room(s) for this session?

Number of encounters per SP

 
Length of simulation encounter  
 minutes
 
SP feedback required?
 
 
Type of feedback
 
 
Length of feedback
 minutes
 
SP training provided by:
 
 
SP Trainer name
 
 
SP Trainer phone number
 
 
SP Trainer email
 
 
SP training Date/Timemm/dd/yyyy
 Calendar  
 
 
SP training location
 Note: If using our facility, please book the rooms
 

NOTE: Training should be scheduled within the same pay-period as the session. A table of pay-periods can be found HERE. If this is not possible, training should be scheduled within seven (7) days of the session.

 
Specific SP requirements (i.e. Number, Gender, Age, Health, Race, etc.)
 
 
 Submit as HTML
 

Additional Requirements:

  1. Please submit case notes (if applicable) with your request, including all checklists and feedback forms via email to the SPC. List of designated SPC can be found in http://umanitoba.ca/faculties/medicine/education/ed_dev/clsf/4986.html
  2. To ensure prompt and efficient service please provide your requests 4-6 weeks in advance of training.
Standardized Patient program fees:
  1. Level of payment will be determined in conjunction with the SPC depending on the case requirements for the SP.
  2. Please see SPP Fee Schedule for description of Standardized Patient Levels and corresponding fees.
  3. Please note that there will be a minimum charge of 3hrs per session for all sessions lasting less than 3 hours.
Our commitment to You:
  1. Confirmation of your request will be sent within 24-48hrs upon receipt of this form.
  2. We will inform you in the event of our inability to complete your request with 5 working days
  3. Notification of booked SPs will be sent to the contact individual within 10-14 days of initial request.
  4. Once this request is processed we will provide you with an estimate for this project. Please return the accepted estimate along with the authorizing signature.