SIM Center Scheduling Request Form

Please fill out the following form for each activity/educational session you are interesting in having at the Simulation Center. Please provide as much information as possible so that we can efficiently manage resources and be prepared to help the session be a success for you and learners. In addition, we would like the requests at least four to six weeks in advance of the session date in order to complete preparation of space, resources, equipment and or curriculum. In addition, our schedule is generally booked out 4-6 weeks in advance. We will contact you within 3-5 business days to confirm and to set up planning. The simulation center will be requiring simulation training to those who develop/write, run and debrief simulation scenarios starting in March 2015. A link to information on ISEC’s simulation training class will be provided at the end of this form.

General Information
Date:
Your Name:
(Firstname Lastname)
Credentials/Title:
(MD, NPR, etc.)
eMail:

Course/Session Title:
 

Hospital/Institution/University affiliation:
(UofM, HCMC, or NA if none)
 

Department/Specialty/Unit or Educational Program:
(Surgery, Peds, etc.)
 

Is the contact person also the instructor or facilitator:
 

yes
no
If not, or if there are additional instructors, please list all instructors:
How many learners/participants:
 
Type of learners participating:
 
Physician faculty
Residents
APPs (i.e., PAs, NPs)
Nurses
Paramedics or other prehospital personnel
RTs
HCAs
Other
Describe other:


If your course includes learners who are not HCMC employees, what percentage of external learners do you anticipate having? %

Will learners be paying a
fee to take your course?

 
yes
no

If yes, who will pay fee? Internal Participants
External Participants
  
Type of educational activity:
Resources
What type of resources do
you anticipate using:

 
Simulation mannequins (Sim Man, Sim Mom, Sim Newborn, Sim Baby, Sim Youth)
 
Please describe mannequin type and number:
Standardized patients (please identify what roles you would like them to play and how many you need)
 
Patient roles:
Task trainers (please identify which task trainers you would like available)
 
Please describe:
Other equipment or supplies
 
Describe other:
Assistance with Scenario Development
 
Describe:
Debriefing Assistance
 
Describe:
Integration of Simulation into Existing Educational Curriculum
 
Describe:
Assistance to Obtain CEU, Board Credits, or CME Credits
 
Describe:

 
Curriculum Information
Is this part of an overall department/unit/residency curriculum or an isolated
educational session
?

 
overall department/unit/residency curriculum
isolated educational session

recurrent educational session
If recurrent, how often will this be repeated:
If recurrent, 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.)
Is this part of a larger educational simulation curriculum for your department/unit/program?

 
yes
no
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)
 
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
If HCMC Sim Center, check all the rooms you would like to use:
I will need assistance in determining rooms
High Fidelity Sim Room 1 (like adult ICU rooms or inpatient room)
 
High Fidelity Sim Room 2 (with OR lights and ED stab room boom)
 
Observation debriefing room Number of rooms: 1 or 2
 
Observation debriefing room 2
 
Task training/skills room
 
Alcove; can select one or two

In-Situ (in your department/unit)
Offsite

location if in-situ or offsite:
Assessment
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.)
yes
no

Please describe:
The Simulation Center has developed a program evaluation/learner survey. Would you like to modify it for your session?
yes
no
Dates/Times
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.)

 
Preferred project date
 and time:
Alternate project date #1
 and time:
Alternate project date #2
 and time:
Alternate project date #3
 and time:
Alternate project date #4
 and time:
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.)
yes
no
Any additional comments: