Request Clinical Competency Center (CCC) Event

Fill out this form in order to request an event in the Clinical Competency Center (CCC).

Event Details

A short description to explain the nature of a ticket.
Is this associated with a JSMBS student course?
Is this associated with a JSMBS student course?
Will any non-JSMBS external equipment / food be required for your event?
Will any non-JSMBS external equipment / food be required for your event?

If you change your mind and require external equipment / food for your event, please notify us as we need 30 days notice to submit the applicable paperwork.

Will a vendor/product representative be involved with your event?
Will a vendor/product representative be involved with your event?

If you change your mind and require a vendor/product representative for your event, please notify us as we need 30 days notice to submit the applicable paperwork.

Will the vendor/product representative be interacting with the learners?
Will the vendor/product representative be interacting with the learners?
Are there new cases that need to be developed or edited?
Are there new cases that need to be developed or edited?
Will there be roleplayers?
Will there be roleplayers?
Do you have a script prepared for the roleplayers?
Do you have a script prepared for the roleplayers?
Are there checklists involved with the case? (If yes, please use the "Attachments" field below.)
Are there checklists involved with the case? (If yes, please use the "Attachments" field below.)
Is there a rubric involved with the case? (If yes, please use the "Attachments" field below.)
Is there a rubric involved with the case? (If yes, please use the "Attachments" field below.)
Will there be a pre-/post-encounter assessment? (If yes, please use the "Attachments" field below.)
Will there be a pre-/post-encounter assessment? (If yes, please use the "Attachments" field below.)
Will you be recording your learners?
Will you be recording your learners?
Will you require recordings after the event? (Downloaded and exported video)
Will you require recordings after the event? (Downloaded and exported video)
Will you require grades/reports after your event?
Will you require grades/reports after your event?
Are you the department PI / cost-approver?
Are you the department PI / cost-approver?
Do you have a UB Blue Services / iLab Account?
Do you have a UB Blue Services / iLab Account?
IF YOU DO NOT HAVE A UB BLUE SERVICES / iLAB ACCOUNT:
https://www.buffalo.edu/administrative-services...

Simulation Material

I confirm that I will provide ALL finalized simulation material (e.g., case, debriefing guide, pre-work) at least six weeks prior to the event date.

I confirm.
I confirm.
File attachments associated with the ticket.
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Requestor Details

Other Fields

Your name
Verification Code