CSP Equipment Rental Application

If you are interested in using Clinical Simulation Program resources but don’t require the use of our full facility, you can rent equipment. We offer a variety of manikins and trainers to meet your educational needs.

"*" indicates required fields

Use this form to request and reserve equipment from the UW Health Clinical Simulation Program. Equipment requests are subject to the Clinical Simulation Program's internal schedule and must be completed at least two full business days prior to the requested pickup date. If you are interested in using the clinical simulation facility, please fill out an application for use form.

Name*

First Last

Email*

Your Department*

Learner Information

Learner Affiliation

UW Health employees

SMPH students

Other Learner Affiliation

Who are your learners?*

About how many learners will use the equipment?*

Equipment Request

Type of Equipment Requested*

Where will the equipment be used?*

Equipment Pickup and Return

Pickup Date and Time*

Add additional rows to offer more than one pickup option.

Date

Time

Person Picking up Equipment*

First Last

Phone of Person Picking Up*

Will this person also be returning the equipment?*

Yes

Person Returning Equipment*

First Last

Phone of Person Returning Equipment*

Return Date and Time*

Use the plus symbol to additional rows and more return options.

Date

Time

CSP Equipment Rental Application

Learner Information

Equipment Request

Equipment Pickup and Return

Policy and Information Sharing Agreements