Case, Simulation, and Task Training Request Form 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 FormIf 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*Facilitator/ Faculty Name* First Last Email* Phone*Additional Facilitators Yes No Additional Facilitator/FacultyFirstLast Add RemoveName and short description of event*Date* MM slash DD slash YYYY Requested Start Time* Hours : Minutes Requested End Time* Hours : Minutes Expected # of learners for date:* Will this activity require a second date?* Yes No Date MM slash DD slash YYYY Requested Start Time Hours : Minutes AM PM AM/PM Requested End Time Hours : Minutes AM PM AM/PM Expected # of learners for date: Will this activity require a third date? Yes No Date MM slash DD slash YYYY Requested Start Time Hours : Minutes AM PM AM/PM Requested End Time Hours : Minutes AM PM AM/PM Expected # of learners for date: Will this activity require a fourth date? Yes No Date MM slash DD slash YYYY Requested Start Time Hours : Minutes AM PM AM/PM Requested End Time Hours : Minutes AM PM AM/PM Expected # of learners for date: Will this activity require a fifth date? Yes No Date MM slash DD slash YYYY Requested Start Time Hours : Minutes AM PM AM/PM Requested End Time Hours : Minutes AM PM AM/PM Expected # of learners for this date: Who is your learner group?(select all that apply) Clerkship Dental Fellows IPE Medical Students NP Nurses PAs PA Students Pharmacy Residents Other (please use text box below) Do you require Standardized Patients?* Yes No 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 No Are there any changes to the case/simulation/equipment/etc that need to be submitted?*YesNoWill you need Zoom?* Yes No 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 No Which of the following would you like assistance in creating? Simulation Case Simulation Template or Case Document Drop files here or Select files 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 No 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 No Which task trainers/equipment do you require?* Airway head – adult Airway head – pediatric Airway head – infant Anesthesia machine Arterial line trainer Blue phantom – vascular Blue phantom – pelvic Breast model Bronchoscopy Central line trainer (Adult) Central line trainer (Pediatric) Chest tube trainer CMAC Crash Cart CVL trainer Difficult airway trainer FLS trainer Glidescope Harvey Injection Knee Injection Shoulder IO Trainer – adult IO Trainer – pediatric Lumbar puncture – adult Lumbar puncture – infant Male model OB Suzie trainer *not ultrasound compatible* OB Zoe trainer *not ultrasound compatible* OR sim Pacer man Pelvic model Peripheral IV arms PICC man Premie Anne Sonosim Surgery Abdomen Ultrasound – older version Ultrasound – sonosite Ventilator Zoll Defibrillator Not Listed (please provide info below) Chest tube trainer size?Trauma manTrauma childPlease chose the desired chest trainer.Chest tube insertion kit10-12 Fr12-16 Fr16-20 Fr20-22 Fr22-24 Fr24-28 Fr28-32 Fr32-42 FrPlease chose the desired chest tube size.Crash cartAdultPediatricNeonatalPlease chose the type of crash cart required.Lumbar puncture kitAdult: 20ga, 3.5-inch spinal needlePediatric: 20 or 22ga, 2.5-inch spinal needleNeonate: 20 or 22ga, 1.5-inch spinal needlePlease chose the desired LP kit sizeHow 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 flushIncluded 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 flushIO 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 flushInfant 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: 2Adult 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, BVMLP kit includes: 4 collection tubes, Monometer with 3-way valve, 5 cc syringe, 18G or blunt needle, 25 g or 27 g needleIncluded with OB Suzie: birthing baby, rod (to push baby out manually), placenta, umbilical cord, lube, cervixIncluded with OB Zoe: lube, speculum, multiple cervices and uteriIncluded 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.
