Simulation & Task Training Request Form Please use this form to schedule time at the Center for Experiential Learning (CELS). A sample scenario can be found here. Please use this form to schedule time at the Center for Experiential Learning. Simulation & Task Training Request Form**If this is a new activity, the request may require a consultation with the CELS staff. ** With each simulation activity that is scheduled, we need to obtain information about the following requirements. All Request for simulation include Simulation Technologist support and designated debriefing room. Scenario Development form can be found under Training/Faculty Development/Simulation Adjuncts.Department name* Requestors Name* First Last Email* Phone*Name and short description of eventDate MM slash DD slash YYYY Requested Start Time* : Hours Minutes Requested End Time* : Hours Minutes Facilitator/ Faculty Name* First Last Expected # of learners Who is your learner group? clerkship/med student/ PA student fellows residents nurses IPE APPs Will you need Zoom?* Yes No Please list three learning objectives (what you expect your learners to take-away) from this session.*Simulation scenario Drop files here or Select files Max. file size: 125 MB, Max. files: 5. Please upload the simulation scenario, with flow chart and script, to be used during your session. Template can be found on the Training/Faculty Development/Simulation Adjuncts page.How many simulation scenarios will you run at the same time? How many simulation scenarios will be run serially (one after another)? What simulators do you require?* Adult Birthing simulator Child Infant Premature other Note- there are several adult simulators that may be used almost interchangeably.If other please describe below i.e. ventilator capabilityWhat task trainers do you require?* Airway trainer (adult) Airway Trainer (infant) Airway trainer (peds) Difficult Airway trainer Arterial line trainer Blue phantom ultrasound Central line trainer Chest tube insertion Crash Cart (adult) Crash Cart (peds) Crash Cart (neonatal) Defibrillator (Zoll) IO Trainer OB Suzie trainer OB Zoe trainer Peripheral IV arm Peripheral IV leg n/a HiddenYou selected a task trainer, which of the following do you need?* Chest tube insertion Newborn-1yr (3-5kg) 10-12 fr 1-2yr (6-9kg) 12-16 fr 2-4yr (10-11kg) 16-20 fr 2-4yr (12-14kg) 20-22 fr 5-7yr (15-18kg) 22-24 fr 5-7yr (19-22kg) 24-28 fr 8-11yr (23-30kg) 28-32 fr > 11yr (>30kg) 32-42 fr Arterial line trainer Peripheral IV arms Central line trainer IO Trainer Infant Airway Trainer Adult Airway trainer Difficult airway trainer OB Suzie trainer OB Zoe trainer Defibrillator #1 Crash Cart #1 Defibrillator #2 Crash Cart #2 Blue phantom ultrasound n/a Other special equipment:* Ultrasound Ventilator C-Mac n/a If additional equipment needed but not listed above please specify below*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:Will your scenario require embedded participants? Yes No Not sure An individual other than the patient, who is scripted in a simulation to provide realism, additional challenges, or additional information for the learner, e.g., paramedic, receptionist, family member, laboratory technicianIf using embedded participants please describe what role will be played belowDoes this require the development of a new simulation/scenario* yes no If this is your own simulation scenario, may we post it to the Bridge for use by others? Yes No Depends on the case, please ask first If immersive simulation, please describe the case including room set up requested*Include the NAME of the case and provide a description. If not applicable list "n/a".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.RESEARCH COMPONENTIf you think your simulations may have a research component now or in the future, please select "Yes" or "Maybe" to the Research question. Will these simulations be used in as part of a research project? Yes No Maybe (unsure) Is this a research project using simulation?* yes no See our Research page,url listed below to copy/paste, for additional required documents if you marked "yes" to the questions above. Please upload the completed files here. Drop files here or Select files Max. file size: 125 MB. http://com-simulation-csalt.sites.medinfo.ufl.edu/research/Have you met with our Research Director, Dr. Rosemarie Fernandez? Yes, already met. No, let's schedule a time. Not yet, already scheduled though. Potential researchers need to meet with us a minimum of 12 weeks in advance. By checking this box faculty member has reviewed and approved this form* reviewed and approved by faculty CAPTCHA
