Simulation Request Requested Day of Activity Requested Day of Activity: Date Requested Day of Activity: Time Case Title Insert Patient's Name, Age, Gender, or Patient Diagnosis Target Audience Specify Student/Course Number/ and Year of Training as Appropriate Primary Contact Name Primary Contact Email Upload the most recent scenario case template 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. Assessment Tools 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. Attach students' information in Excel format in this order: First Name, Last Name, User Name, Email, User Number (VERY IMPORTANT Make sure this name matches with what the student is called and their academic record. If there is additional names the student goes by please note in spreadsheet) One file only.150 MB limit.Allowed types: xls, xlsx. Anticipated Number of Rooms Needed Estimated Name and Roles of Faculty Involved Day of Event Estimated Number of Simulated Participants (if applicable) Equipment Required Feedback/Debriefing Plan What faculty is leading and what is method of distributing information to students How are students being assessed? (if applicable) Do students need to see post reports, if so which data is appropriate? Which faculty is releasing scores and when? Yes No Which faculty is releasing scores? When will scores be released? (If new case) Proposed Planning Meeting Date (If new case) Proposed Planning Meeting Date: Date (If new case) Proposed Planning Meeting Date: Time (If new case) Case Script or Template Due Date (2 months before event) (If new case) Case Script or Template Due Date (2 months before event): Date (If new case) Case Script or Template Due Date (2 months before event): Time Additional Comments Leave this field blank
