The Center of Nursing Excellence

An initiative of the Southern Virginia Higher Education Center

General Reservation Requisition

Name:
Today's Date:
Business/Organization:
Date(s) Requested:
Time(s) Requested:
Number Attending:
Contact Person:
Contact Number:
Contact Email:
Area Requested:
Special Equipment Needs (i.e. manikins, task trainers, etc.):
*If requesting Advanced Simulation Lab or Birthing and Newborn Simualtion Lab areas complete the following:
Advanced Simulation Lab or Birthing and Newborn Simualtion Lab
Level of Student (i.e. CNA, RN, LPN, EMS, etc.):
Simulation Scenario/Disease Process (contact the Associate Director of The CNE for a listing of available pre-programmed scenarios):
Learning Objectives:
Special Instructions or Request (if specialized scenario is needed):
Expectations from Lab and Lab Specialist: