VCU Clinical Learning Center - Request CLC Activity

Please complete this form to reserve space for activities in the Clinical Learning area. This information will be used to develop a centralized schedule for the lab, and help us prepare for your time in the area.

First Name : Last Name:

Today's Date:

Course: Semester: Please Select Spring Summer Fall

Requesting CLC for date(s) and time(s)[If you will be using the CLC for multiple dates and times, please indicate the complete list of dates and blocks of times. For example: 5/25/07 8am - 4:30 pm, 5/30/07 3pm - 4pm]: **Please note** Request of the CLC for large activities should occur before the beginning of the semester allowing staff ample time to prepare.

Faculty Members present:

Name: Email:

Name: Email:

Name: Email:

Number of Students per date:

**Please note** If not School of Nursing students, then we will contact you about billing information.

Learning Objectives:

Equipment Needed:

Uniform of the Day: Please select SON Uniform Business Attire and Lab Coat Not Required

Responsibilities of CLC Staff:

• Have equipment set up at least 30 minutes in advance
• Direct operation of the CLC
• Clinical Feedback Sheets if behavior observed (consultation with faculty)

Responsibilities of Faculty:

• Dress: Lab coat or scrubs, faculty preference
• Assure preparation of any other faculty assisting
• Assure readiness of students
• Notify students as to the uniform of the day
• Provide students with written objectives for the activity
• Arrive at least 15 minutes before start time
• No guests without permisssion

Faculty & CLC staff will meet 2 week before the scheduled time.

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