MITIE Internal Event Request

Thank you for choosing MITIE to host your event!

Please complete this form with as much information as you can so we will better understand your needs and goals. Once MITIE receives this form, a project coordinator will be contacting you within two business days to discuss your request in more detail.

Event Details

Event Title * Event Requested By * Physician Fellow Resident Researcher Nurse Other Clinician (please specify) Other Staff (please specify) If other, please specify Department * Requester Name * Phone Number * Email Address * Specialty * Advanced Heart Failure & Transplant Cardiology Anesthesiology Cardiac Electrophysiology Cardiovascular Disease Colon & Rectal Surgery Congenital Cardiac Surgery Critical Care Medicine Dermatology Electrophysiology Emergency Medicine Endocrinology Gastroenterology General Surgery Hematology Infectious Diseases Interventional Cardiology Nephrology Neurological Surgery Neurology Nursing Obstetrics & Gynecology Oncology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine & Rehabilitation Plastic Surgery Pulmonary Disease Quality / Education Radiology Reproductive Medicine Thoracic Surgery Transplant Surgery Urology Vascular Surgery Other If Other, please specify * Subspecialty * Requested Date [1st Choice] * Requested Time [1st Choice] * Requested Date [2nd Choice] Requested Time [2nd Choice] Lab Type * Dry Wet - Animate Wet - Cadaveric SIM 3G Manikin Explants Video (Broadcast, Livestream, and/or Recording) If wet lab requested list out; needs, quantity and procedures & specs If Animate Lab [Need PI Name] Space Requested * MRI Angio Suite CT OR Operating Room 1 Operating Room 2 Partial Task A Partial Task B Partial Task C Partial Task D PSL 6 PSL 9 SIM 1 SIM 2 Extended Reality MPS Board Room Conference Room A Conference Room B Conference Room C Conference Room D Conference Room E Conference Room F Broadcast Studio A Broadcast Studio B Participants * Surgeon Physician Fellow Resident Medical Student Advanced Practice Providers (PA or NP) Nurse Other Allied Health Professional Industry Support Other If Other, please specify * Anticipated Total Number of Participants * Name of guest that will be attending or assisting with this request Name of non-Houston Methodist guest, if applicable Detailed Description *

Billing Information

Department Administrator Name * Email Address * Department * Phone Number * Project ID [If Applicable] Cost Center # for internal transfers * Fund # (if applicable) for transfers

Authentication *