Event Request Form - Immersive Learning and Digital Innovation

Requestor’s Phone Number(Required)

Requestor’s Email Address(Required)

Name of the Course(Required)

Course Number(Required)

Name of the Course Coordinator(Required)

Name of the Program(Required)

Purpose of your Request

Name of sponsoring/funding agency

Name of the principal investigator

Internal Order or Budget Number

What division do you belong to?

Name of the Course

Course Number

Name of the Course Coordinator

Research Title

IRB Number

Name of sponsoring/funding agency

Name of the principal investigator/Responsible Faculty

Internal Order or Budget Number

Start Date of Event

End Date of Event

If other, please specify

Objectives of your activity(Required)

Description of your activity(Required)

Resources Needed

If Yes, How Many Patients Needed?(Required)