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Opioid Kit Loan Form

Please use this form if you are interested in borrowing an Opioid Simulation kit. Please complete the form below and a SimUAB® team member should contact you within 24 business hours. Borrower is responsible for damages to kits while on loan. Kits must have scheduled pick-up and return times scheduled with SimUAB®. For additional assistance please contact simuab@uab.edu .

Requestor Name

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Phone

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Employer

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If other, please specify

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Blazer ID

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Title

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Approximately, how many learners will be participating?

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How many kits do you need?

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When will you pick up the kit(s)?

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When will you return the kit(s)?

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Would you like to pick up your kits in Volker Hall or have them delivered to you?

Pick up kits in Volker Hall

Deliver kits to me

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Where would you like your kits delivered? (UAB building and room number)

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Please list any comments

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(*)

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