CELS Reservation Request Form Additional Forms and Agreements For EXTERNAL users Authorization and Consent to Photograph and Publish Confidentiality Agreement For INTERNAL users myTraining – Confidentiality & Consent for Photography Please use this form to schedule time at the Center for Experiential Learning. Room reservation request questionnaire**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 participantsWill you need live streaming?*YesNoWhat clinical environment do you want to replicate?* Crical Care Space OR Emergency Bay Hospital Room Other How many simulation secnarios will you run at the same time?How many simulation scenarios will be run serially (one after another)?What simualtors do you require?* SimMan3G 1 SimMan 3G 2 Meti Man Victoria (birthing simulator) Hal (child) Tory (infant) Hank Gaumard Adult n/a 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 more than one simulator to be used simultaneously, please explain below so we can understand space, resource and technician needs:Note- there are several adult simulators that may be used almost interchangeably.Does this require the development of a new simulation/scenario* yes no 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".Is this a research project using simulation?* yes no If this simulation is for research purposes please describe your research below.*If yes, please describe in text box. If not applicable list "n/a".
