Contact the Simulation and Interprofessional Education Center

• Simulation and Interprofessional Education Center (SIEC)
  University of Mississippi Medical Center
  2500 N. State St., SM409
  Jackson, MS 39216-4505
  (601) 815-9082
  siec@umc.edu

Simulation Session Request Form

* = Required Fields

Faculty
Full Name:*	*
Email Address:*	*Invalid Email
Department(s)
Participants
Types of participants (check as many as applies)* Undergraduate medical education Undergraduate healthcare provider education (SOD, SOP, SON, SHRP) Graduate medical education Healthcare team (postgraduate) CME From UMMC External Interprofessional Other (please specify) *
Other type of participants
Level of participants*	*
Number of participants*	*
Education session
Proposed session dates:
Learning objectives/educational rationale (e.g. learn to intubate, teamwork in OR crisis)*	*
Simulation environment Simulation center (SIEC) In-situ Other (please specify)
Other simulation environment
Research & evaluation Potential for research (please describe) Patient outcome or quality initiatives Educational metrics/assessment Other
Potential for research description
Other research & evaluation
Funding (if applicable)