Form Contact:

For general questions or inquires about scheduling, please contact:
Carol Okupniak, MSN, RN
Director of the Center for Interdisciplinary Clinical Simulation and Practice
Telephone: 215-762-4148

Form Instructions:

Please fill in the items below. Items marked with a red asterisk (*) are required fields. Press the "SUBMIT" button to send this information to a CICSP Staff Member. For a submission example, please the Sample Submission Form

Submission Instructions:

1. The room request must contain the name and phone number of the person filing the request.
2. The course name must follow the following formats:
   • Nurs 300 - Comprehensive Adult Nursing
   • Nurs 303 -Women's Health Workshop
3. You may select more than 1 day per submission for the same course reservation only.
4. Please select a range of students that best fits your courses needs
5. Select your primary room followed by a secondary / alternative room. In order to request 2 rooms you must check the box marked "check to request both rooms"
6. If you request linens, you will be supplied with the max number of students requested plus an additional 20%
   • 40-60 Students will yield the following when towels are requested:60 students x 20% = 12 additional towels for a total of 72 towels
   • You may request additional linens in the Notes/Special Instructions Field

NOTE: Incomplete requests will be declined.