Please use this form to submit a request for the purchase of new or replacement equipment for use in simulation-based education at UTMB. Requestor's First Name Requestor's Last Name Requestor's Email Address: Requestor's role at UTMB: - Select - Faculty Staff Requestor's affiliation: - Select - JSSOM SON SHP SPPH GSBS UTMB Health System Other What equipment would you like purchased: Equipment Manufacturer: Equipment Model: Cost of Equipment: Quantity Needed: Are additional parts needed to be purchased in order for this equipment to work properly: No Yes If additional parts are needed to operate this equipment, please make sure the additional parts are included in the requested quote for the equipment. Please upload a quote obtained for desired equipment: This field is required s When is this equipment needed by (date): Submit