Simulation Activity Request Form
Activity requests for new activities should be submitted no later than 11 weeks prior to when the activity should run. (See the Simulation Activity Timeline for activity development.)
Client Details
Organization Name
Primary Contact Person
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Secondary Contact Person
First Name
Last Name
Secondary Contact Email
example@example.com
Secondary Contact Phone Number
Please enter a valid phone number.
Logistics
Date(s) you are requesting for the activity to take place. If it is new activity, please leave a time allowance for a practice run of the activity to be scheduled at least one week prior to the activity taking place. Choose your preferred start date:
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Month
-
Day
Year
Secondary Start Date (If preferred date is not available.)
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Month
-
Day
Year
Secondary Start Date
Number of times the activity should run
Date and time within the next two weeks that you and your team are available to meet with us and go over your activity request.
Learner Details: List number of participants, learner level, profession type, and any other pertinent information that will help us understand who the participants are.
Activity Details
Give a brief description of the activity.
List activity learning objectives and how it corelates to your program. (Ideal 3; no more than 5 learning objectives.)
List existing activity materials (e.g. case, scripts, assessment tools, equipment, checklist, etc.)
Activity Assessment Type:
Formative (learning experience / performance improvement, non-graded)
Summative (graded as part of a course / competency assessment)
High Stakes (must pass simulation experience to proceed)
Further comments or details:
Submit
Should be Empty: