Queen Elizabeth Hospital
Office Hours: 09:00-18:00 (Mon-Fri, except public holidays) Saturday: Special arrangement upon request
Closed on Sunday and Public Holiday
Part I
A. Contact Information
Main Organizer/
Hospital
Department
Prof. Dr. Ms. Mr. Name
Program Director Position Email
Tel Fax
Corresponding Person
(if different from the
Course Director)
Position
Tel
Prof. Dr. Ms. Mr. Name
Email
Fax
B. General Booking Information
Event Nature: a. Simulation based (please submit together with the Curriculum Proposing Form -FM006 & Scenario Flow)
b. Skill Based b. Lecture c. Meeting d. Others
Proposed Date(s)
Event Time
No. of Events
No. of participants per class
Event Title ii) Doctors Nurses Allied Health Others:______________
C. Additional Information (For skill based training and lecture use only)
Objectives
Speaker/Instructor(s)
(with professional qualification/expertise)
Course Content
Set up date and time
Version: Nov 2014
Set down date and time p.1 of 4

Course Nature
Confirmation of Venue Booking
Simulation # /
Skill Based
Lecture Others
Organizer
KCC
Society, Association,
College, Other clusters,
HAHO
Once the application has passed the MDSSC
Screening Process
(around 2 weeks)
Outsider
*Booking will open 1 year before the event.
1 month before
Lecture Rm
Simulation OR + Control Rm
Simulators (for simulators >150k)
Endovascular Lab
Wet Lab
On-site AV technical support
Course administration (incl: poster design, email notifications, registration, hand-out and equipment preparation, house-keeping)
KCC / MDSSC organized internal training
KCC Departments or College/ Academy co-organized training activities (endorsed by COS/DM)
Society / academic bodies organized
Commercial-based activities
Version: Nov 2014 lecture date
1 week before event
# If apply for simulation-based event, the program director needs to submit curriculum proposing form to
MDSSC 2 months before the event
Charging
HK $ 500 /hr
HK $ 500/ hr
HK $ 500/ hr
HK $ 500/ hr
HK $ 500/ hr
Complementary
X 1.5 of total rental charges
No charges
50% (If co-organized with KCC
Departments)
100%
200% p.2 of 4

Booking Policy
 Simulation program application should be submitted at least two months before the course date. Skill based, lecture and other applications should be submitted at least one month before the course date.
 Training course that involves a new/existing curriculum has to be submitted at least two months before the course date.
 Availability of technician/ administrative/ housekeeping assistance in non-office hour will not be guaranteed and will be subjected to manpower availability.
 When applying a Simulation Program, this booking form MUST be submitted together with the Curriculum
Proposing Form & Scenario Proposing Form. Please return the completed form and related documents to
MDSSC by fax or email.
 Previously finalized and approved curriculum can be reused for subsequent training. Applicant, however, has to notify MDSSC for any amendment on your submitted/existing curriculum.
 If the program is scenario-based, please submit the scenario flow no later than one week after submitting your application. All scenarios should undergo trial run before actual training.
 Successful applicant will be notified by email from MDSSC office that includes confirmation of training date and schedule.
 Please list all the required equipment, medical consumables and setting in the curriculum proposing form.
Please communicate with our staff early for preparation of equipment/consumables.
 MDSSC will not bear the cost of courses held.
 For outside applicant, cancellation fee applies if booking is only cancelled in less than a week before the course date. MDSSC reserves the right to deny your future application.
 MDSSC reserves the right to deny your future application if severe discrepancy is found between the course and the original description on the booking form and submitted documents.
 Simultaneous activities may go on in different areas in MDSSC.
 Course outside work hours needs Centre Director’s approval.
 MDSSC reserves the right to accept or reject any application.
 MDSSC reserves the right to assign any staff/room to facilitate the course.
 Outside applicant assumes the responsibility to replace, repair, and all associated expenses for any defacement and / or damage to the facility caused by the applicant, and his associate(s), or his representative(s).
I have read and understood the information provided to me regarding the booking/charging policy of MDSSC.
I hereby agree to the terms above.
Name of Program Director Endorsement by COS / DOM (if applicable)
Signature Date:
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) 3506 8771 Fax: (852) 3506 7045 E-mail: qeh_mdssc@ha.org.hk
Version: Nov 2014 p.3 of 4

Part II (For MDSSC use only)
Nature of function
Availability of requested date
If not, proposed date(s) for requester’s consideration
Yes No
CHARGES Waived
50 % discount
Full payment Total charges:_HKD____________
Approval by Director of MDSSC
Condition of booking
Approved by
Date confirmed
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 waiting list rejected
Payment received on (if applicable)
Version: Nov 2014 p.4 of 4