HSM Room and Equipment Request Form

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HSM Room and Equipment Request Form

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Date of Request«

Today's Date

Event Name«

Contact Name:«

Point of Contact

Contact E-Mail«

Confirmation sent here

Contact Phone«

Phone number to reach you

Start Time«

HH:MM AM/PM

End Time«

HH:MM AM/PM

Preparation Time

Addtl time before actual start of presentation

Begin Date«

MM/DD/YYYY

End Date«

MM/DD/YYYY

Recurrence

Use Ctrl key for multiple selection

Frequency

Select from list, if applicable

Estimated Attendance«

To determine room size

Preferred Room«

Select from list

Room-Other

If selected, please specify

Appear on Event Calendar?

Event will be added if Yes

[ Yes ] [ No ]

Event Info

Upload flyer or info to post

Event Topic

If no upload, type topic here.

Equipment Needed«

Please select from list.

[ Yes ] [ No ]

Equipment Requested

check all that apply

Camera-Digital

Camera-Video

Conference Phone

DVD

Laptop

Projector-Transparency

Tegrity Cart

Tripod

TV/VCR

VCR

Other

Other Equipment

enter if you selected Other

Fields marked with "«" are required.

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Department of Health Systems Management
Tulane University School of Public Health and Tropical Medicine
1440 Canal Street, Suite 1900, New Orleans, La 70112
504.988.5428 phn 504.988.3783
hsm@tulane.edu