CSEAC Procedural/Patient Simulator session Reservation Request Form

Reserved by (Full Name) * You must specify a value for this required field. Researsed_x0020_by_x0020__x0028_ Department * You must specify a value for this required field. Department Phone number * You must specify a value for this required field. Phone_x0020_number Course * You must specify a value for this required field. Course Email address * You must specify a value for this required field. Email_x0020_address Event date * You must specify a value for this required field. Your input is invalid. Event_x0020_date Beginning Time * You must specify a value for this required field. Beginning_x0020_Time Ending time * You must specify a value for this required field. Ending_x0020_time Event Title * You must specify a value for this required field. Event_x0020_Title Will your department faculty be attending the session? * You must specify a value for this required field. Will your department faculty be attending the session? Yes Will your department faculty be attending the session? No If yes, who? If_x0020_yes_x002c__x0020_who_x0 Is this a reoccurring event? * You must specify a value for this required field. Is this a reoccurring event? Yes Is this a reoccurring event? No If yes, please list the additional dates and times of each event below If_x0020_yes_x002c__x0020_please If training Medical Students Year 1, How many? Your input is invalid. If_x0020_training_x0020_Medical_ If training Medical Students Year 2, How many? Your input is invalid. If_x0020_training_x0020_Medical_0 If training Medical Students Year 3, How many? Your input is invalid. If_x0020_training_x0020_Medical_1 If training Medical Students Year 4, How many? Your input is invalid. If_x0020_training_x0020_Medical_2 If training Residents PGY1, How many? Your input is invalid. If_x0020_training_x0020_Resident If training Residents PGY2, How many? Your input is invalid. If_x0020_training_x0020_Resident0 If training Residents PGY3, How many? Your input is invalid. If_x0020_training_x0020_Resident1 If training Residents PG4-7, How many? Your input is invalid. If_x0020_training_x0020_Resident2 If training Fellows, How many? Your input is invalid. If_x0020_training_x0020_Fellows_ If training Faculty, How many? Your input is invalid. If_x0020_training_x0020_Faculty_ If training Nurses, How many? Your input is invalid. If_x0020_training_x0020_Nurses_x If training other than those above, please specify If_x0020_training_x0020_other_x0 Does your event need to be recorded? * You must specify a value for this required field. Does your event need to be recorded? Yes Does your event need to be recorded? No Will you be debriefing your event if it is recorded? * You must specify a value for this required field. Will you be debriefing your event if it is recorded? Yes Will you be debriefing your event if it is recorded? No Do you need a digital/AV system (i.e. PowerPoint)? * You must specify a value for this required field. Do you need a digital/AV system (i.e. PowerPoint)? Yes Do you need a digital/AV system (i.e. PowerPoint)? No If yes, please provide details If_x0020_yes_x002c__x0020_please0 What type(s) of space(s) are you looking for? Please check all that apply * You must specify a value for this required field. Small Laboratory Large Laboratory VCC/Simulation Bay Ultrasound Room Debrief Room Surgery Room Lecture Room Do you need Equipment & Supplies? If yes, check all that apply below * You must specify a value for this required field. Do you need Equipment & Supplies? If yes, check all that apply below Yes Do you need Equipment & Supplies? If yes, check all that apply below No Carts Adult Code Cart Airway Cart Drug Cart Pediatric Code Cart Equipment & Patient Support Anesthesia Machine Anoscope IO Drill Ventilator Kits Arterial Line Kit Central Line Kit Chest Tube Kit Cricothyrotomy Kit Foley Kit Incision and Drainage Kit Intubation Kit Lumbar Puncture Kit NG Tube Kit Paracentesis Kit Pericardiocentesis Kit Thoracentesis Kit Vascular Access Blue Phantom 2 Vessel Blue Phantom Branched Vessel Blue Phantom CVC Torso Blue Phantom Nerve Block Blue Phantom Nerve Block CVC Landmark Puncture Pad CVC Ultrasound Puncture Pad Simulab CentraLineMan Ultrasoundable Simulab FemoraLineMan Ultrasoundable Patient Simulators ALS Trainer (Heart Sim) Laerdal 3G Laerdal SimMom Laerdal SimNewB METI ECS METI HPS METI iStan Virtual Reality Simulators Endoscopic Virtual Reality Trainer Laproscopic Virtual Simulator Ultrasound Models Trained Standardized Ultrasound Patient (Person) Ultrasound Vaginal Model "LuLu" (Task Trainer) Ultrasound Ectopic Endovaginal Model (Task Trainer) Ultrasound Amniocentesis Model (Task Trainer) Ultrasound Machines Sonosite M-Turbo a) phased array probe b) linear probe c) curvilinear probe Micromaxx a) curvilinear probe b) endoluminal probe c) phased array probe d) linear probe GE Logiq 5 a) phased array probe b) linear probe Bard Site Rite 3 a) mechanical linear array probe Task Trainers Advanced Childbirth Trainer Arterial Arm Trainer AT Kelly Airway Trainer Auscultation Torso Basic Pelvic Exam Trainer Birthing Model Blaufuss Stethoscope Pads Condom Model Double Breast Exam Trainer Ear Trainer Gynecologic Trainer Individual Breast Exam Trainer Joint Injection Model- Elbow Joint Injection Model- Knee Joint Injection Model- Shoulder Joint Injection Model- Wrist/Hand Knot Tying Board Laerdal Airway Trainer Lumbar Puncture Trainer Male Foley Model Without Base Male/Female Foley Trainer METI Advanced Pelvic Exam Simulator Prostate Examination Trainer Rectal Examination Trainer TraumaMan Uroscopic Trainer Venous Arm Trainer Testicular Trainer Defibrillators Lifepak 9 Lifepak 12 Lifepak 20 Please list any additional supplies not listed above that are needed for this event: Please_x0020_list_x0020_any_x002 If you chose a patient simulator from the above list, will a staff member be needed to operate the simulator? If you chose a patient simulator from the above list, will a staff member be needed to operate the simulator? Yes If you chose a patient simulator from the above list, will a staff member be needed to operate the simulator? No If you are doing ULTRASOUND, would you like to have Trained Simulated Ultrasound Patients (TSUPs)? If you are doing ULTRASOUND, would you like to have Trained Simulated Ultrasound Patients (TSUPs)? Yes If you are doing ULTRASOUND, would you like to have Trained Simulated Ultrasound Patients (TSUPs)? No If so, how many Trained Simulated Ultrasound Patients will you need? If_x0020_so_x002c__x0020_how_x00 For your ultrasound sessions, which anatomy do you plan to visualize? For_x0020_your_x0020_ultrasound_ Additional comments pertaining to this overall request: Additional_x0020_comments_x0020_ Type your question here... Type your question here... Enter Choice #1 Type your question here... Enter Choice #2 Type your question here... Enter Choice #3  Submit

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