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 event

Date

Requested Start Time*

:

Requested End Time*

:

Facilitator/ Faculty Name*

First Last

Expected # of learners

Limited to 10 per room due to COVID-19

Who is your learner group?

clerkship/med student/ PA student
fellows
residents
nurses
IPE
APPs
Other (please use text box below)

Will you need Zoom?*

Yes
No

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

Simulation scenario template

Drop files here or

Max. file size: 125 MB.

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 capability

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

What task trainers do you require?*

Hidden

You selected a task trainer, which of the following do you need?*

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 applicable

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 technician

If using embedded participants please describe what role will be played below

Does 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 COMPONENT

If 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

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