Healthcare Theatre Request Form
Please complete the following form to the best of your knowledge. Questions or concerns regarding this form can be sent to Javonte Perry, Healthcare Theatre Program Coordinator (jtperry@udel.edu)
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Institution Making Request *
Contact Name *
Contact Phone Number *
Contact Email *
Have you worked with Healthcare Theatre before? If yes, please list the past Course Title, Simulation Title, and Date(s) *
Requested Simulation Date(s) *
Time(s) *
Location (Full Address) *
Type Of Simulation *
Obligatoria
Total Number of Simulation Hours *
How Many Standardized Patients are you requesting to participate in the Simulation? *
How many simulation rooms will you be running at a time? *
Character Information / Demographic *
Simulation Learning Objectives (What are you hoping to obtain out of this experience?) *
In a few sentences, please describe the details you would like included in the scenario. *
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