Project Request

Welcome to our Simulation Request form. This online tool will help us to conceptualize and implement your simulation, training session, or event. New requests may require additional consultation with Sim Center staff to ensure that we provide the best overal experience. Sim Center staff will assist you in planning, developing, and evaluating the effectiveness of your event. Due to the high demand for simulation space, we ask that you plan 6 to 8 weeks in advance as we may be unable to accommodate late requests.

Reservation Form

Submission of this form does not guarantee the availability of space or resources.

This form will not save. Be sure to have all information available at the time of completion. For more information about available resources, please visit our equipment and lab space page.

Provide your contact info:

Name: *

Title: *

Department: *

Phone

Confirm Email

Please list any co-facilitators (including contact information):

Project: Provide a few lines of information for each section of the form.

Title of Project: *

Crash Cart Request for Training:

Please select this checkbox only if you are a unit educator and are requesting a crash cart for training purposes related to Zoll Defibrillator or crashcart familiarization.

Please note that the crash cart provided is equipped with simulated medications and equipment and is not intended for patient use. It should only be used for training purposes and not for emergency situations. The cart should not be left unattended on the unit floor and staff should be notified of it's presence.

By checking this box, you acknowledge that you have read and understood the above information, and that your request for a crash cart is for authorized training purposes only.

In-Unit CPR and Crash Cart Training Request

Use this field to request in-unit CPR and crash cart training that will be tailored to your unit's needs. Our Sim Center educators will work with you to develop and implement the training in your unit, taking into account your team dynamics and the specific challenges that you face.

Please detail your request:

Purpose and goals: *

Please provide an overview of your project:

Timeline (projected dates for first session and recurring dates): *

Number of learners

Date of tour:

Timeline (include set-up and date of event):

Number of participants (Include all facilitator and any presenters):

Audience

Select all that apply

Number of rooms requested (A request of more than 4 patient rooms and 1 conference room will require review)

Brief background (i.e.: rationale, context, applicable literature, preliminary work): *

Project plan and methods: *

IRB application status IRB application status

Please upload your IRB submission (not required)

Maximum upload size: 52.22MB

Please upload any associated documentation (I.E. scenarios, vital changes, flow charts etc...)

Maximum upload size: 52.22MB

Will you require standardized patients (a specialist portraying a patient situation)?

Will you require a CPR Manikin?

Will you require a Cardiac Rhythm Simulator?

Will you require a patient simulator?

Type of manikin requested (select all that apply)

Adult

Pediatric

OB/GYNOB/GYN

Neonatal

Will moulage be required?

Yes

*If yes, you must outline details in the project plan and methods field. This also must be coordinated with a Sim Tech prior to implementation.

Please list any additional task trainers or anatomical models that may be needed:

Type of task trainer/anatomical model requested:

Will you require Audio/Visual support:

Select all that apply

Please upload any files required for presentation:

Maximum upload size: 52.22MB

Program evaluation plan (General plan for evaluating knowledge skills gained from this course): *

Agreement

All requests for the use of the University of Chicago Simulation space must be affiliated with the University of Chicago Medicine, Biological Sciences Division, or University of Chicago. All visitors to the Simulation Center must sign in using our data management system and provide feedback using a provided evaluation form.

I agree to these terms.

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