Simulation Event Request
Please submit your request at least 12 weeks in advance to ensure schedule availability. We will review it and get back to you in a week or so. Thank you.
Activity
Name of Activity
*
Type of Activity (check all that apply)
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Standardized Patient (If yes, you will be contacted by a member of our education team for planning)
Scenario-based simulation (If yes, we will send a scenario template. Requires scenario pilot four weeks in advance)
Skills-based simulation
Scenario/Skills-based combined
Point of Care Ultrasound (POCUS)
Student Interest Group
Interprofessional Education
Faculty Development/Continuing Professional Development (CPD)
CME (Licensing)
School or Community Group
Tour
Research
Room Use (no staff support or equipment needed)
Equipment Only
Conference
Please name your group
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Is this a recurring activity with no changes from last session?
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Yes
No
Is this a:
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New Event
Revised Event
Does your program's accrediting board require this training activity?
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Yes
No
Please name the accrediting board and requirement
*
Is there a vendor or industry sponsor?
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Yes
No
If yes, please identify
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In one or two sentences, please state the aim of the simulation activity and why it is needed.
Contact Information
Name
*
First Name
Last Name
Role
*
Instructor/Facilitator
Student
BCM Department Administrator
School or Community Representative
Industry Representative
Vendor
Other
Please name your faculty sponsor
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
School/Department/Organization
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Course Name and number (if applicable)
Schedule
Desired Date(s)
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Alternative Date(s)
Desired Start Time
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Estimated Duration of the Activity (minutes or hours)
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Will this be a recurring event?
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Please Select
Once
Daily
Weekly
Monthly
Biannually
Annually
Participants
Primary Facilitator for this Event
*
How many facilitators will be present for the activity?
*
Learner Affiliation
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Undergraduate Medical Education
Graduate Medical Education
School of Health Professions
Affiliate Hospital
External to BCM
Other
Specify affiliation:
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Who are the learners? (Check all that apply)
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MS1
MS2
MS3
MS4
PGY-1
PGY-2
PGY-3
PGY-4
PGY-5
PGY-6
PGY-7
PGY-8
Fellows
Faculty
PA Student
OP Student
GC Student
DNP Student
Advanced Practice Provider
Other
How many learners will participate?
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Facilities, Equipment and Supplies
Will you need equipment? (Check all that apply)
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No
High-fidelity Advanced Simulator (e.g., SimMan, FLS, GI BronchMentor, TEE)
Task trainer(s)
Ultrasound (machine, probe, gel, cleaner, wipes)
Ultrasound Compatible Trainer
Other
Please list the task stations and specific trainers you will need for your event.
*
Will tissue models (e.g. animate, phantom) be needed for this activity?
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Yes
No
Tissue model source:
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Vendor Supplied
Department Supplied
Simulation Supplied
Will physical exam simulated patients be needed? Note: PESPs are used as models for ultrasound activities.
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Yes
No
What is your preferred room type? (check all that apply)
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Clinical Examination Room (Simulated Outpatient Room)
Task Training Room
Operating Room
Classroom
Wet Lab
Conference Room
What audio-visual support will you need?
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Presentation
Recording (SIMULATIONiQ)
Will you provide a checklist/evaluation form?
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Yes
No
Funding
How will this activity be funded?
Note: At this time, there is no charge for events that serve BCM learners and trainees.
Administrator for billing
Payment Method (Ex: BCM Cost Center, Check, PO#, Credit Card)
Note: Payment is not processed at time of request.
Case Scenario
Please provide any additional details and attach case scenario if applicable.
Case Scenario or other activity materials
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