SIU School of Medicine Foundation Springfield Office

Telehealth and Video Services - SIU School of Medicine


Conference Room Reservation Form

To best serve you, we ask that you please schedule videoconferences and audioconferences at least one week in advance.

(NOTE: fields with an asterisk are required)

Today's Date:
*Requestor's Name:
*Requestor's E-mail:
Program Information:
*Organization Name:
*Meeting Name / Purpose:
*Meeting Coordinator Contact:
* Meeting Coordinator E-mail Address:
*Meeting Coordinator Phone Number:
*Meeting Coordinator Fax Number:
*If outside entity, SIU Sponsor:
Meeting Specifics:
*Date Needed:
* Room requested:
* Begin Time:
*End Time:
* Table Setup:

rectangle  u-shaped classroom double not-required
(click on the setup style to view room configurations)

Maximum Number of Attendees:
Recurring Meeting:
Recurring Schedule:
If any Audio/Visual items are needed, please indicate below:
Flip Chart LCD Projector Document Camera Laptop Connection
Fax Machine 35mm Slide Projector VCR Internet Connection
Copy machine Overhead Projector Computer** Chromakey

** Additional Computer Information:
Conference room PCs are DVD ready and have Microsoft Windows XP/MS Office 2003 (Word, Powerpoint, Excel and Access) loaded in the 409 West Calhoun conference room and Microsoft XP/MS Office loaded in the 913 North Rutledge conference room. If more than one PC is required please call (217)545-7830 to schedule a time to come to the Conference Room to show where laptops will be used so we are certain the appropriate ports are active.

If audioconference or videoconference capabilities are needed, please indicate below:
Audioconference Speaker Phone
(Allows 1 incoming or outgoing call with 360° voice clarity for large group participation)
Standard Speaker Phone*
(Allows 6 simultaneous calls, but minimal voice clarity-good for small groups)
(Allows live two-way audio and two-way video communication to 1 or more locations)

Additional Videoconference Information:

(This information must be filled out if videoconferencing is requested)
Calling Location:
Contact Person:
Contact Number:
*Multiple VC sites required?
If a multi-site VC is requested, you will be contacted for additional site contact information
Audioconference Information:

Audioconferences require a one week advance request for setup.

Guidelines for Conference Room Use
Unless we are notified otherwise, the room will be availble 30 minutes prior to and 30 minutes after the meeting to allow for set up and clean up.
Will food be served at this event?
The conference room will be available 30 minutes before and after your scheduled meeting time in order to allow for set-up and cleanup. If serving food and / or beverages, there is a kitchen area available at 409 West Calhoun for your use but PLEASE LEAVE IT CLEAN. Kitchen appliances include an electric stove with four burners, oven, microwave and full size refrigerator. There is a coffee / hot water maker, but you are responsible for providing the coffee and / or tea, as well as any other refreshments. It is also your responsibility to provide any tableware, condiments, paper and / or plastic goods that you may need.
We hope you have a pleasant experience using the Telehealth Networks and Programs Conference Room. Please give us any comments or suggestions, so that we can improve the experience for others.

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No information received through this form will be shared with or sold to any other parties.
Our customers privacy is our first concern.
The mission of the Southern Illinois University School of Medicine is to assist the people of central and southern Illinois in meeting their health care needs through education, patient care, research, and service to the community.


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