Simulation Equipment Reservation Form Simulation Equipment Reservation Form Please provide your contact info: Title: * Name: * Department: * University Email: * Campus Phone: * Campus Address: * Equipment Requests Task Trainer Central Venous Catheterization (One task trainer) Central Venous Catheterization (Two task trainer) Lumbar Puncture (One task trainer) Lumbar Puncture (Two task trainer) Paracentesis (One task trainer) Thoracentesis (One task trainer) CPR Mannequin (Upper body, Adult Male) CPR Mannequin (Infant) DaVinci Robotic Surgery simulator GI Bronch Mentor LapMentor Inventive HeartWorks TTE/TEE Mannequin Laerdal Sim Man 3G* Laerdal SimMan* Laerdal SimMom* Laerdal SimJunior* Laerdal SimBaby* Laerdal SimNewB* Peds HAL* ECMO Baby* * Mannequins with asterisk must be accompanied by Simulation Center Technical Specialist. Medical Equipment Sonosite Ultrasound Machine Dr CART simulated Code Cart Philips Defibrillator (1) Philips Defibrillator (2) Other Video recording Please provide dates for your event (please provide multiple options as other simulation events may be scheduled): * 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. As a custodian for equipment that belongs to the Simulation Center, I will ensure it’s stored and used appropriately and safely returned to the Simulation Center at the end of my reservation. Some equipment may have associated consumable costs that require reimbursement. * I agree to these terms. This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit Share this:TwitterLinkedIn
