Simulation Request Requested Day of Activity Date Start Time End Time Case Title Insert Patient's Name, Age, Gender, or Patient Diagnosis Target Audience Specify Student/Course Number/ and Year of Training as Appropriate Facilitator Name Upload the most recent simulation template? (Found on Simulation canvas site ) i.e. Skills Request Form, Simulation Design Template, SPCase TemplateOne file only.150 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp4, ogg, wav, svg, zip. Assessment Methodolgy Curriculum Requirement - None - Yes No Not Sure Explanation of Curriculum Requirement Assessment Tools (Faculty Rubric / SP Checklist)One file only.150 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp4, ogg, wav, svg, zip. Anticipated Number of Rooms Needed Name and Roles of Faculty Involved Day of Event Will Simulated Participants be involved in the event? Equipment Required Feedback/Debriefing Plan (when, where, type: summative or formative) What faculty is leading and what is method of distributing information to students If applicable, when should videos/checklists be released? Proposed Planning Meeting Date (If new case) Proposed Planning Meeting Date: Date Proposed Planning Meeting Date: Time Complete Case Information Due Date (Required 6 weeks before event. Appointment will be sent as a reminder) Complete Case Information Due Date: Date Complete Case Information Due Date: Time Proposed Dry Run Date (If new case. Best within 2 weeks of the event) Proposed Dry Run Date: Date Proposed Dry Run Date: Time Additional Comments Leave this field blank
