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Mississippi Academy for Simulation Training
Mississippi Academy for Simulation Training
Mississippi Academy for Simulation Training Home
MAST Onsite Student Group Simulation Request Form
MAST Faculty Online Foundations Training Request Form
Main Content
MAST Faculty Online Foundations Training Request Form
*
= Required Fields
Requested semester of training
*
Spring 2023
Summer 2023
Fall 2023
Spring 2024
Nominee
*
Email
*
Phone
*
(
)
-
Last 4 digits of the nominee's SSN
*
Nominee's Date of Birth (MM/DD/YYYY)
*
Is the nominee a current or former UMMC employee or student?
*
Yes
No
If Yes, please provide the employee ID number.
Simulation Years of Experience
*
Nominating Institution
*
Nominating Administrator
*
Administrator Email
*
Administrator Phone
*
(
)
-
Please list the name of alternate nominee, in the event the first nominee is unable to participate.
*
Alternate's Email
*