Evaluating Healthcare Simulation

Evaluating Healthcare Simulation

Instrument Requests
Please submit the following information to request permission to use one of the simulation evaluation instruments:
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Organization*
Organization City*
Organization State (Abbreviation) or Country, if outside US*
Instrument Requested (submit separate form for each request) *
How Do You Plan to Use the Instrument? (choose all that apply)*

Evaluate the Instrument's Potential UsefulnessResearchStudent CompetencyFaculty CompetencyOrganizational AssessmentCurriculum EvaluationMaster's ThesisPhD DissertationDNP ProjectScreen-based SimulationOther
Who will the instrument be administered to? (choose all that apply)*

FacultyStaffStaff Development EducatorsAdministratorsNursing Students (Diploma, Associate)Nursing Students (Baccalaureate)Nursing Students (Graduate)Medical StudentsMedical ResidentsAllied Health StudentsNursesPhysiciansHealthcare Practitioners (not MD/RN)Other
By submitting this request,

I understand that I have been granted permission by the creators of the requested evaluation instrument to use it for academic and/or research purposes.

I agree that I will use the evaluation instrument only for its intended use, and will not alter it in any way.

I will share findings as well as publication references with the instrument creator(s).
Should be Empty: