Kowloon Central Cluster
Document No. / KCC/QE/MDS/MDS/FM/0004 / Effective Date: / 01.02.2017
Department: / Multidisciplinary Simulation and Skills Centre / Next Review Date: / 01.02.2019
Type Of Document: / Form / Version: / Feb 2017 (v.4)
Title: / Venue Booking Form / Page: / 1 of 2

Multi-Disciplinary Simulation and Skills Centre

Queen Elizabeth Hospital

Tel: (852) 35068771Fax: (852) 3506 7045E-mail:

Monday to Friday: 09:00-18:00 (except public holidays) Saturday and non-office hour: Special arrangement upon request

Closed on Sunday and Public holiday

Venue Booking Form

A. Contactinformation

Mainorganizer/hospital
Department
Programdirector / Prof Dr. Ms. Mr. / Name
Position / Email
Tel / Fax
Corresponding person
(if different from the programdirector) / Prof Dr. Ms. Mr. / Name
Position / Email
Tel / Fax

B. General Booking Information

Event Nature: Simulation based(please submit together with the Curriculum Proposing Form–FM006 & Scenario Flow)

Skill Based Lecture Meeting Others

Proposed date(s) / Time
No. of class / No. of participants/class
Program title
Target participants / i) KCC staff only All HA staff Others:
ii) Doctors Nurses Allied health Others:
Room Required (optional) / Endovascular Lab Lecture Room Operating Room
Resuscitation Room Procedure Room
Special Request

I have read and understood the information provided to me regarding the booking/charging policy of MDSSC, I hereby agree to the terms and conditions set forth in the document.

Name of Program Director / Endorsement by COS / DOM (if applicable)
Signature / Date:

C. Additional Information (For Skill based training and/orLecturetrainingonly)

Objectives
Speaker/Instructor(s)
(with professional qualification/expertise)
Course Content
Set up date and time / Set down date and time

Please complete and return this form to Multi-Disciplinary Simulation and Skills Centre

4/F, Block F, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon

Tel: (852) 35068771 Fax: (852) 3506 7045 E-mail:

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.Part II (For MDSSC use only).

General information

Nature of booking / Simulation based Skill based Lecture Meeting
Others
Room / Endovascular Lab Lecture Room Operating Room
Resuscitation Room Procedure Room
Room availability / Yes No, proposed alternate date:
Pre/post booking / ASTC ECMO Central Intern
Charges / Waived 50 % discount Full payment / Total:HKD$

Approval by Director of MDSSC

Booking / Confirmed Waiting list Rejected / Date
Approved by / Dr. NH Chia Dr. Eric So Dr. George Ng / Signature

Checklist

Booking request forward to Director for approval on
Confirmation / Notification sent to requester
through written / email / fax on
Received booking confirmation from requester on
Reminder sent to requester on
Payment received on (if applicable)