Title of simulation experience:

Identifying Information

Your name:

Department/program:

Email:

Address:

Phone:

UDDS/department number:

Fund type:

Project number:

Learners/participants:

(Examples: M4, PGY1, post-op surgical nurses, pharmacy tech)

Are the learners familiar with simulation?

Select ...YesNo

Number of participants:

Preferred dates:

Preferred times:

Estimated duration of the simulation:

(Example: 2 hours)

Frequency:

(Examples: monthly, once per semester, etc.)

Proposed location:

(Examples: Clinical Simulation rooms CSC/H6/1, Children's Hospital room __, Pediatric ICU, etc.)

Description of the Simulation

Case names (example: malignant hypothermia, anaphylaxis, team communication):

Describe what the participants will do:

Logistics and Estimated Time for Each

Learner orientation (include duration):

(Examples: 15-minute intro and review of logistics; 20 minutes didactic)

Encounter (include duration):

(Example: two 10-minute cases with manikins)

Debriefing (include duration):

(Example: 40-minute learner-led discussion using attached self-evaluation tool)

Total time (estimated):

Equipment Needed

Required medical or simulation equipment:

(Examples: manikin, lumbar puncture torso, etc.)

Supplies and Devices

Will you be providing medical supplies and devices?

(Example: IV start kit)

Select ...YesNo

Audio/Video

Is capture required?

Select ...YesNoNot Sure

Simulation Goals and Objectives

Please send any additional case materials or attachments to George Keeler at gkeeler@uwhealth.org.

Goal(s): what should learners know or be able to do as a result of this event?

(Examples: cognitive skills, psychomotor skills, tasks or behaviors)

Primary objectives (list no more than five):

(Examples: 1. Perform neurological assessment after trauma; 2. Evaluate patient assessment information including vital signs; 3. Recognize and treat neurogenic shock; 4. Initiate vasoactive medication treatment; 5. Recognize and treat respiratory failure. See attached guidelines for writing objectives.)

Citations

Are you aware of any literature relevant to your simulation? Please list:

Miscellaneous

Please list any other special needs: