(MD, NPR, etc.)
(UofM, HCMC, or NA if none)
Department/Specialty/Unit or Educational Program:
(Surgery, Peds, etc.)
Is the contact person also the instructor or facilitator:
If not, or if there are additional instructors, please list all instructors:
How many learners/participants:
Type of learners participating:
Will learners be paying a
fee to take your course?
Type of educational activity:
Skills instruction workshop
Standardized patient encounters
What type of resources do
you anticipate using:
Is this part of an overall department/unit/residency curriculum or an isolated?
overall department/unit/residency curriculum
isolated educational session
Is this part of a larger educational simulation curriculum for your department/unit/program?
If this session is part of a larger simulation curriculum, please describe the goals/objectives of your overall curriculum:
(We recommend 3-4 primary curriculum goals/objectives if possible)
Will this specific educational session be repeated in the future?
If yes, when do you anticipate this may occur?
If your curriculum or session requires routinely scheduled or recurring dates/times, please propose which dates and/or days of the week and times you would like to reserve the Simulation Center, and the duration of your course.
(i.e., reoccurs 1x/week for 2 months every Monday from 8-12, reoccurs 1x/month for 3 years on the first Friday of the month from 8-12, etc. or list all dates needed. Please note that the ISEC can only be reserved up to 1 year in advance.)
Individual Session Information
Please describe the goals/objectives of this specific session and desired learner outcomes:
(We recommend 2-4 primary goals/objectives per session, if possible.)
Please include any additional learner or instructor needs:
Project location preference:
(If in-situ or offsite, include location and specific rooms.)
HCMC Simulation Center
In-Situ (in your department/unit)
location if in-situ or offsite:
Will there be any evaluation/ assessment incorporated into this session?
(Evaluation of the sesssion by the learners, evaluation of the learners by the instructors, etc.)
If this is a single educational session or if you are starting a recurring session, please propose your preferred project date and time for the first session:
(We prefer requests 6 weeks in advance of proposed date in order to complete preparations.)
Are there CMEs or CEUs
involved in the project?
(If so, the CME or CEU certification must be obtained by your group through avenues outside of the Simulation Center staff.)
Any additional comments: