Simulation & Task Training Request Form Simulation and Task Training Request Form 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. Department name*Requestors Name* First Last Email* Phone*Name and short description of eventDate Requested Start Time* : HH MM Requested End Time* : HH MM Facilitator/ Faculty Name* First Last Expected # of learnersLimited to 10 per room due to COVID-19Who is your learner group? clerkship/med student/ PA student fellows residents nurses IPE APPs Other (please use text box below) Will you need Zoom?*YesNoPlease list three learning objectives (what you expect your learners to take-away) from this session.*Simulation scenario template Drop files here or Please upload the simulation scenario, with flow chart, and script to be used during your session.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 Female (birthing simulator) Child Infant Premature other If other please describe below i.e. ventilator capabilityNote- there are several adult simulators that may be used almost interchangeably.What task Trainers do you require?* Chest tube insertion 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 use the text box below*list "n/a" if not applicableIf 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?YesNoNot sureAn 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?YesNoDepends on the case, please ask firstIf 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?YesNoMaybe (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 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
