Center for Experiential learning Request Form

Please use this form to schedule time for simulation and/or Standardized Patient needs

"*" indicates required fields

Simulation | Task Training | Standardized Patient Event Form

If this is a new activity, the request may require a consultation with the CELS staff.

Department Name*

Activity*

Course Name*

Point of Contact*

First Last

Email*

Phone*

Is the Point of Contact the same as Facilitator/Faculty?*

Yes

Facilitator/ Faculty Name*

First Last

Email*

Phone*

Additional Facilitators?

Yes

Additional Facilitator/Faculty

First

Last

Name and short description of event*

Date*

Requested Start Time*

Requested End Time*

Expected # of learners for date:*

Will this activity require a second date?*

Yes

Date

Requested Start Time

Requested End Time

Expected # of learners for date:

Will this activity require a third date?

Yes

Date

Requested Start Time

Requested End Time

Expected # of learners for date:

Will this activity require a fourth date?

Yes

Date

Requested Start Time

Requested End Time

Expected # of learners for date:

Will this activity require a fifth date?

Yes

Date

Requested Start Time

Requested End Time

Expected # of learners for this date:

Who is your learner group?

(select all that apply)

Do you require Standardized Patients?*

Yes

Demographic Request (age/gender/specific needs – e.g. fluent in Spanish, overweight, etc):*

Length of encounters (e.g. 10 min case + 10 min post encounter = 20 min total encounter):*

What additional components will be included in this activity?*

Select all the apply

Debrief Room

Post Encounter Note

SP Checklist

SP Verbal Feedback

Video Recording

Length of PEN*

If multiple, please elaborate.

Specific debrief-room request?*

How would you like the results of this activity handled?*

I would like to review the results prior to any result release to learners

I would like the results to be released directly to learners without my review

I would like the results and the itemized checklists released directly to learners without my review

Have you completed this form in the past for this course?*

Yes

Are there any changes to the case/simulation/equipment/etc that need to be submitted?*

Will you need Zoom?*

Yes

Please list three learning objectives (what you expect your learners to take-away) from this session.*

Would you like assistance with crafting a new simulation or case document?*

Yes

Which of the following would you like assistance in creating?

Simulation

Case

Simulation Template or Case Document

Drop files here or

Max. file size: 125 MB.

Please upload the case and/or simulation scenario, with flow chart and script, to be used during your session.

Will there be multiple high-fidelity simulations running at the same time? Will there be serial high-fidelity simulations (one after the other)?

No; there will not be tandem NOR serial simulations

Yes; there will be tandem simulations but NOT serial simulations

Yes; there will be serial simulations but NOT tandem simulations

Yes; there will be BOTH tandem simulations AND serial simulations

How many high-fidelity simulations will run TANDEM?*

How many high-fidelity simulations will run SERIALLY?*

Do you require simulators?*

Yes

What simulators do you require?*

Adult

Birthing simulator

Child

Infant

Infant Lung

Premature

Toddler

Other

N/A

Note: there are several adult simulators that may be used almost interchangeably.

If 'other', please describe below (i.e. ventilator capability)

Do you require task trainers/additional equipment?*

Yes

Which task trainers/equipment do you require?*

Chest tube trainer size?

Please chose the desired chest trainer.

Chest tube insertion kit

Please chose the desired chest tube size.

Crash cart

Please chose the type of crash cart required.

Lumbar puncture kit

Please chose the desired LP kit size

How many peripheral IV arms are needed?*

Chest tube sterile tray includes: 4 x 4’s, 2 x 2’s, Drapes, Curved mosquito hemostat, Curved Kelly clamp, Scissors, Needle holder, Chest tube or pigtail – Scalpel – 4-0 silk suture on cutting needle – Petroleum-soaked gauze – Underwater sealed drainage system or a “Heimlich” valve

Included with art line kit: – Radial artery catheter kit – Arrow kit – Chucks

Included with adult CVL kit: 5-7 FR Triple-lumen catheter (or introducer catheter/Cordis), 5-10 mL syringe (for venipuncture), 18-ga needle (for venipuncture), Guidewire, Scalpel with 11-blade, Dilator, Catheter clamp, Silk suture, Biopatch, Tegaderm, Sterile saline flush

Included with Pediatric CVL kit: 5-7 FR Triple-lumen catheter (or introducer catheter/Cordis), 5-10 mL syringe (for venipuncture), 18-ga needle (for venipuncture), Guidewire, Scalpel with 11-blade, Dilator, Catheter clamp, Silk suture, Biopatch, Tegaderm, Sterile saline flush

IO trainer includes: Pediatric and adult IO trainers, 2 IO guns, Manual IO, Yellow, pink and blue IO needles, IV tubbing connection, 5-10 mL syringe, Saline flush

Infant airway includes: Pediatric airway heads, NPA size: 20, OPA size: 6.5, ETT: 4.5, Stylet: 10FR, Colorimetric: smallest size, In line ETCO2, Lubrication, BVM, Mac 1,2,3, Miller 1,2,3, WIS 1,2,3, LMA size: 2, King tube size: 2

Adult airway includes: Adult airway heads, NPA size: 26, OPA size: 10cm, ETT sizes: 7.5, Lubrication, Stylet: 12FR, Handle w/ working light, Mac 3,4, Miller 3,4, Colorimetric, In line ETCO2, LMA size: 4, King tube size: 4, Bougie, BVM

LP kit includes: 4 collection tubes, Monometer with 3-way valve, 5 cc syringe, 18G or blunt needle, 25 g or 27 g needle

Included with OB Suzie: birthing baby, rod (to push baby out manually), placenta, umbilical cord, lube, cervix

Included with OB Zoe: lube, speculum, multiple cervices and uteri

Included with the ultrasound IV trainer: US, lubrication, 24g IV catheters, syringes, alcohol prep pads, towels. Included with the CVL trainers: US, lubrication, towels, Size 9 double lumen CVL kit.

Please specify which equipment you require.*

Only enter information into the text box below if the equipment for your case/simulation is NOT listed above. Please consult the list thoroughly.

If you are requesting multiple simulators or task trainers to be used simultaneously, please explain below so we can understand space, resource and technician needs including how many task trainers are needed:

If you have other needs that have not been addressed above please feel free to add them here, including the need for repeating a simulation on multiple dates, special meeting requests, etc.