Task Training Form Task Training From use this for if you ONLY need task training Department name*Nursing, PA, COM, etc.Requestors Name* First Last Email* Phone*Name and short description of eventDate requested* Requested Start Time* : HH MM Requested End Time* : HH MM Facilitator/Faculty Name* First Last Expected # of learners*Limited to 10 per room due to COVID-19Will you need Zoom?*yesnoWho is your learner group?* clerkship/med student/ PA student fellows residents nurses IPE Select the task trainers you will need* Airway head - adult Airway head - pediatric Airway head - infant Airway head - difficult Art line Blue phantom - vascular Blue phantom - pelvic CVL trainer FLS trainers Harvey IO leg - adult IO leg- pediatric Knee Lumbar puncture - adult Lumbar puncture - infant OBGYN trainer - Susie OBGYN trainer - Zoe OR sim Pacer man PICC man Premie Anne Shoulder Sonosim Surgery Abdomen Trauma man Trauma child None Please select the specialized equipment you need* Anesthesia machine Bronch cart CMAC Glidescope Ultrasound - sonosite Ultrasound - older version Ventilator None Please list needed consumable supplies and the quantity needed*examples: 3 x ET size 7.0 tubes, (5) 22G needles, 2 qty. size 7 double lumen CVL procedure traysBy checking this box you confirm faculty has reviewed/approved this request.* reviewed and approved
