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Center for Experiential Learning & Simulation

College of Medicine

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Training
CELS Reservation Request Form

Training Overview

CELS Reservation Request Form

CELS Reservation Request Form

Additional Forms and Agreements

We need the Simulation Scenario Template completed at the time of the reservation request with an ACCURATE equipment list. We cannot guarantee the availability of equipment that is not on the reservation. If in doubt please arrange phone call or meeting with simulation center staff.

For all users using simulations (Example Scenario)

Simulation Scenario Template

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 event
Date
Requested Start Time*

: HH

MM
Requested End Time*

: HH

MM
Facilitator/ Faculty Name*
First Last
Expected # of learners
Will you need live streaming?*
- Yes
- No
live streaming is a video relay that allows participants to view simulations in real time in an alternate location
What environment do you want to replicate?*
- Critical Care Space
- OR
- Emergency Bay
- Hospital Room
- Other
If other please describe your needs below (example, space for lecture)
Please 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 secnarios 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, including if you need ventilation capable manikin
Note- 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 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 you scenario require confederates?
- 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 confederates 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
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".
If you think you may like to use your simulations in research please give a brief description below.
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.

Center for Experiential Learning & Simulation

College of Medicine

Utility Links

Bridge Group
College of Medicine
Office of Educational Affairs

Physical Address: P.O. Box 100259
HMEB 4th Floor
Phone: 352.273.9697
Email: simulation@med.ufl.edu

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