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Clinical Teaching and Assessment Center Request Form
This is a request form for resources of the Health Sciences Learning Center’s Clinical
Teaching and Assessment Center (CTAC). Complete the sections below and email this
form to Angie Bass at arbass2@wisc.edu. The CTAC staff will then draft a blueprint and fee
estimate, and this will be sent to you. Note: Required classes do receive space and support
services priority.
1. Program/Project Information:
a. Name of project:
b. Description:
Teaching
Research
Assessment
Other:
c. Contact person and department:
d. Funding source if applicable (grant, departmental funds, etc., including fund
numbers if available):
e. Amount of funding available (if known):
f. Funding contact person:
2. Preferred dates:
a. Frequency (e.g., one-time, monthly, quarterly, annually):
b. Specific calendar date(s):
c. Preferred day(s) of week:
3. Preferred exam times:
a. Time of day (e.g., morning or afternoon):
b. Start time (e.g., 4:00 p.m.):
c. Finish time (e.g., before 6:00 p.m.)
4. Participant profile and number:
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a. Students:
b. Residents:
c. Physicians/clinicians:
d. Other:
5. Approximate number of rooms needed (number of stations, encounters, etc.)
including conference or meeting rooms:
6. Approximate time per station per learner (e.g., 10 minutes, 15 minutes):
7. I.T. needs:
a. Touch screen laptop (Tablet PC) score entry:
b. Recording of session:
c. Streaming encounters (i.e., viewing session encounters using the web):
c. CD ROM/DVD:
d. Other:
8. Report needs, e.g., global scores, individual station scores, other:
9. Standardized patient needs (number, specific characteristics):
10. If relevant: Remediation plan for participants who do not meet minimal
requirements of the exam:
11. Other: