UChicago Simulation Request Form

We look forward to partnering with you to offer high quality simulation and measure the impact of your intended objectives. Please note the Simulation Center is significantly understaffed, reducing our capacity. We will be reviewing all requests weekly- please expect delays in responses and longer times to availability.

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

Work Email

Confirm Work Email

List all facilitators (including contact information):

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

Title of Project: *

Project Type:

Clinical Simulation (scenario/manikin/vitals)

Clinical/Procedural Skills

Crash Cart Review (unit educators only)

Mock Code

Research project

Surgical Cadaveric Lab (Wet Lab)

Fire Safety Training

OtherOther

What is your IRB number?

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.

Mock Code Request

Use this field to request in-unit mock code training/ 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.

Is this event fulfilling an accreditation requirement?

Yes (please describe)Yes (please describe)

No

i.e. "X simulations are required annually for internal medicine residency program"

Is this event in response to a patient safety event?

No

Yes- list patient safety contactYes- list patient safety contact

What are the learning objectives of the event? (List 1-3 clear goals)

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

Please describe the project approach (how will objectives be achieved)?

How will you measure that objectives are achieved? *

What tools will you use to evaluate objectives?

Would love suggestions

Checklist (observe & document competencies)

Documented findings from DeBrief

Pre/Post Test

OtherOther

Number of anticipated learners

Learner Types (select all)

UChicago Faculty/Staff

UChicago Medicine Employees

UChicago Trainees (residents, students, etc.)

External Faculty/Staff

Community Members/ High School Students

OtherOther

List all requested dates including start and end time: *

Note: Timelines for simulation are longer than normal due to lack of staffing.

What room types are requested?

Patient Rooms (how many)Patient Rooms (how many)

Conference Room

Sim OR

Surgical Lab

Details of room requests (i.e. # ppl, equipment):

Will you require a patient simulator?

Will you require a CPR Manikin?

Will you require a Cardiac Rhythm Simulator?

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

Type of manikin requested (select all that apply)

We can partner with you to identify the best manikin.

List task trainer/anatomical model requested:

Will moulage be required?

Yes

No

*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.

Will you require Audio/Visual support:

Select all that apply

Describe the cadaveric or biological specimen(s) needed

Will a vendor be supplying any of the following?

Cadaveric or biological specimen(s)

Surgical Tools

OtherOther

Select all that apply

Provide the name of your primary vendor contact

First Name

Last Name

Provide the email of your primary vendor contact

List any other surgical tools needed that are not already procured

Please upload any files required for presentation:

Maximum file size: 52.22MB

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

Maximum file size: 52.22MB

Please upload your IRB submission or specific aims

Maximum file size: 52.22MB

Surgical Cadaveric Lab

The surgical cadaveric lab spaces are a shared resource across the entire health system. Even if a simulation specialist is not present during the procedural lab components, each lab requires planning, set-up, clean-up, and appropriate chain of custody for all specimens.

I agree to the following rules:

No eating is allowed in the cadaveric lab spaces
No photography or videography is permitted
PPE is required (minimum of gown and gloves)
All trash will be disposed of properly prior to leaving the lab
Specimens will be treated with respect and identification papers will remain with the specimen at all time
Participants will leave the lab clean after use

surgical lab *

I agree to these terms.

Agreement

I understand that submission of this request does not reserve or guarantee requested dates or resources.

I agree to partner with the Simulation Center team to capture outcomes.

I agree to uphold psychological safety for all participants and treat everyone with respect.

If I publish on this work, I will acknowledge the University of Chicago Medicine Simulation Center in my publication.

*

I agree to these terms.

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