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:
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):
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
Select One Exempt Submitting/Under Review Accepted IRB application status
Please upload your IRB submission (not required)
Please upload any associated documentation (I.E. scenarios, vital changes, flow charts etc...)
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)
Will moulage be required?
*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:
Program evaluation plan (General plan for evaluating knowledge skills gained from this course):
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.
If you are human, leave this field blank.