ATSSL Booking Request Form

Which specific ATSSL space are you looking to reserve?*

Surgical Skills Laboratory = SSL (HRIC BA01)Clinical Simulation Laboratory = CSL (HSC G820)Unsure
Do you require a classroom in addition to your specific ATSSL space request?

YesNo
Will this event be catered?

YesNo
Which procedure(s)/activities will be performed?*
What will you be performing your skills on? *
(i.e. cadaveric material, animal tissue, task trainer)
Do you require any equipment?*

YesNo
Please list what equipment and number of each you will require:*
i.e. Ultrasounds; C-Arm; Surgical Instruments; Computerized Manikins; Synthetic Models
What consumables and what number of each would you like to request?
Please confirm if you require cadaveric specimens. By answering Yes, I acknowledge and affirm that the learners who will be using this educational material and engaging in skill practice activities are entirely within their legal scope of practice.*

YesNo
Which region(s) of the body are required?*
(i.e. head, neck, thorax, upper limb, back, spine, pelvis, lower limb, whole body)
What activity will you be performing?
What quantity of specimens do you require?*
(number)
Which of the following best describes the session you would like to book ATSSL resources/services for?*

Single Day EventMulti-Day Event
How many sessions would you like to book?

2345
Preferred Start Date: *

YearMonthDay
Date
Preferred End Date:

YearMonthDay
Date
Preferred Start Time: *

Please note that the lab opens at 8:30am. If you need access earlier, overtime charges will apply.

AM/PM Option
Preferred End Time:*

Please note that the lab closes at 4:30pm. If you need access later, overtime charges will apply.

AM/PM Option
Preferred Start Date #2:*

YearMonthDay
Date
Preferred start time for Date #2:*

Please note that the lab opens at 8:30am. If you need access earlier, overtime charges will apply. Minutes

AM/PM Option
Preferred end time for Date #2:*

Please note that the lab closes at 4:30pm. If you need access later, overtime charges will apply. Minutes

AM/PM Option
Preferred Start Date #3:*

YearMonthDay
Date
Preferred start time for Date #3:*

Please note that the lab opens at 8:30am. If you need access earlier, overtime charges will apply. Minutes

AM/PM Option
Preferred end time for Date #3:*

Please note that the lab closes at 4:30pm. If you need access later, overtime charges will apply. Minutes

AM/PM Option
Preferred Start Date #4:*

YearMonthDay
Date
Preferred start time for Date #4:*

Please note that the lab opens at 8:30am. If you need access earlier, overtime charges will apply. Minutes

AM/PM Option
Preferred end time for Date #4:*

Please note that the lab closes at 4:30pm. If you need access later, overtime charges will apply. Minutes

AM/PM Option
Preferred Start Date #5:*

YearMonthDay
Date
Preferred start time for Date #5:*

Please note that the lab opens at 8:30am. If you need access earlier, overtime charges will apply. Minutes

AM/PM Option
Preferred end time for Date #5:*

Please note that the lab closes at 4:30pm. If you need access later, overtime charges will apply. Minutes

AM/PM Option
Preferred pickup date:

MonthDayYear
Date
Preferred return date:

MonthDayYear
Date
How many learners are expected to attend this event?*
How many facilitators are expected to attend this event?*
Will you require an estimate for the fees associated with this request?

YesNo
Please indicate which of the following will be used for covering any costs incurred by your request?*

University of Calgary AccountAHS AccountChequeEFTOther
Contact Email for invoice processing. *
Please upload any relevant documents.

Cancelof
Name of File
Conflict of Interest (COI)
In accordance with the ATSSL Operating Standard for Conflicts of Interest and the University of Calgary’s Code of Conduct, all academic staff members, clinical and adjunct appointees, employees, and non-employees/non-appointees who are involved in the design or implementation of simulation or educational activities in the ATSSL are responsible for ensuring that their use of the ATSSL does not result in a perceived or actual conflict of interest.

Prior to using the ATSSL, academic staff, employees, and clinical/adjunct appointees (those subject to the University Code of Conduct) and/or individuals/organizations who do not have an employment or appointment relationship with the University of Calgary but who are involved in the design or implementation of simulation or educational activities in the ATSSL must attest to the following:
I have read and understood the ATSSL Operating Standard for Conflicts of Interest and the University of Calgary’s Code of Conduct documents, and I understand the definition of COI.*

Read and Understood
I (on behalf of myself and my organization, if applicable) do not have a relationship with any Interested Person and am not aware of any conflict of interest; OR, I am aware of a conflict of interest and confirm that it has been disclosed by the appropriate academic staff member, employee, or appointee who has received an approved Conflict Management Plan as per the operating standard and which has been shared with the Manager, ATSSL. I understand that failure to disclose any conflict of interest I am aware of may result in the termination of my booking at the ATSSL and related privileges.*

Read and Understood
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