CFS Request Form - UC San Diego

Contact Information and Event Details

Requester Name*

Company Name and Division*

Email Address*

Phone Number*

Billing Contact Different from Requestor?

Contact Name*

Contact Email Address*

Contact Phone Number*

Course Title*

Course Description and Summary of Procedures*

Estimated Number of Attendees:*

Reserved Parking:

Do you plan to include catering? (Unchecked: NO / Checked: YES)

Event Date #1

Date*

Method(s) of Training
Didactic (Unchecked: NO / Checked: YES)

Hands-on Lab

Lab Setup Date

Lab Start Time*

Lab End Time*

C-arm

Animate Models*

Cadaveric Models*

Other Models*

Details * (Options)

Additional Notes

Lab Imaging
All Imaging must comply with UCSD's Anatomical Policies. Please download and submit the Anatomical Material Use Agreement form.

Are CT Scans required prior to the lab? (Unchecked: NO / Checked: YES)

Are Photos or Videos being taken? (Unchecked: NO / Checked: YES)

Names and Purpose of Participants Taking Images

Addition A/V Needs

Upload Agenda: (Max file size 10MB)

Upload Agreement Form: (Max file size 10MB)

PLEASE NOTE: This form will be used to assess space availability. You will be contacted by an Event Coordinator to confirm your date(s).

Course/Lab Request

Contact Information and Event Details

Event Date #1