Request an Observation or Consultation Name* First Last Email* Enter Email Confirm Email Phone*Department* Role* Member of TEACH* Yes No Requesting which service: Observation Consultation Requested Observer*Choose here:No preferenceJennifer Cleveland, PharmD, BCPS, MBAChad DeMott, MDMisty Flinchum, BS, RRT -Simulation Observation OnlyMahtab (Mattie) Foroozesh, MDTim Fortuna, DO - Simulation Observation OnlyBruce Johnson, MDAnita Kablinger, MDDaniel Lollar, MDShari Whicker, EdD, MEdTeaching activity you would like observed* Is this activity online or in-person? Online (synchronous) In-person Date* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM What are your goals for this observation?Are you requesting this observation for VTCSOM promotion purposes? Yes No When do you anticipate applying for promotion (year)? Have you had a previous observation? Yes No If yes, when was your last observation? Additional Notes [lmt-post-modified-info]
