Please complete the form below to submit your reservation request for the Center for Human Simulation and Patient Safety.
If you are unable to complete the form in one sitting, you may save your progress and return to the form at a later date.You may also modify this form at any time by using the "Save and Return Later" feature where a pass key is generated for you to access your form at a later time. If you have any questions or need assistance while completing this form, feel free to contact the Center for Human Simulation and Patient Safety at 804-628-3925 or email at medsiminfo@vcuhealth.org. __________________________________________________________________________________________________ NOTICE:
Completing this form does NOT confirm your reservation - you will receive separate communications from the Simulation Center when we receive the request and when we are able to confirm/finalize your reservation, after review. REQUESTS SHOULD ADHERE TO THE FOLLOWING TIMELINE FOR CONSIDERATION:• High-fidelity requests (simulator mannequins), Standardized Patient and Ultrasound Patient Models: 8-12 weeks • Low-fidelity requests: 4-6 weeks • Equipment Loan (in Center or outside Center): 2 weeks • Photo shoots: 2 weeks • Tours: 1-2 weeks • Vendor demos: 4-6 weeks
Do you agree to the Guidelines for Reservations outlined on the website?
* must provide value
Yes
No
Your reservation request is unable to be completed at this time.
Please contact Elizabeth Trent, Division Administrator.
Thank you, please continue.
Contact Name:
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Contact Name Email:
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Contact Name Phone Number:
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Department:
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Food and Drinks are NOT allowed in the Sim Center.
Do you require a space for refreshments?
* must provide value
Yes
No
Lobby and Conference Room space is available for food/drink.
What TYPE of reservation are you requesting?
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Simulation Tour Photo/Video Shoot Equipment Loan General Request
Responsible Faculty:
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Responsible Faculty Email:
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Course Title:
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SimulationIQ Calendar Name:
Learning Domains:
Please select all that apply.
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Is this a grant funded project?
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Yes
No
Please provide grant index and grant administrator name:
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Will there be a medical representative/equipment vendor in attendance? Please note, there may be a fee assessed with any vendor demonstration and/or equipment use.
* must provide value
Yes
No
Vendor Name:
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Vendor Email:
* must provide value
Vendor Phone Number:
* must provide value
What assessments/evaluations does this course utilize? Please select all that apply:
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Which Entrustable Professional Activities (EPA) will this course accomplish?
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More than one option may be selected
Where are you taking the equipment?:
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Do you require a tour guide?
* must provide value
Yes No
Is there more than one date for your session?
* must provide value
Yes No
Is more than one date needed?
Are the recurring session(s) requested the same identical session each time that you have requested dates?
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Yes No
If no - you must supply an uploaded document complete with details required for each unique session
Please list all dates/times requested paired with scheduled session/module to be run per date:
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We schedule per half academic year at a time - July-December, and January-June; Please submit two reservations if you are scheduling a year long event. 9th floor Center hours are from 8am-5pm M-Th, 8am-4pm F; For 9th floor use - we cannot promise use outside of these hours.
Please list per date/time requested - number of rooms required per date/time, and number of Learners per room date/time
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We schedule per half academic year at a time - July-December, and January-June; Please submit two reservations if you are scheduling a year long event. 9th floor Center hours are from 8am-5pm M-Th, 8am-4pm F; For 9th floor use - we cannot promise use outside of these hours.
Please list Instructors for each room that you have requested:
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One instructor required per room requested
Date:
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Today M-D-Y Please know the Sim Center follows VCU's holiday closure schedule.
Start Time: (military time)
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Now H:M 9th floor Center hours are 8am-5pm M-Th, 8am-4pm F; For 9th floor use - we cannot promise use outside of these hours.
End Time: (military time)
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Now H:M 9th floor Center hours are 8am-5pm M-Th, 8am-4pm F; For 9th floor use - we cannot promise use outside of these hours.
Pickup Date:
* must provide value
Today M-D-Y Please know the Sim Center follows VCU's holiday closure schedule.
Pickup Time: (military time)
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Now H:M Pickup hours are 8:30am-4pm M-F
Return Date:
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Today M-D-Y Please know the Sim Center follows VCU's holiday closure schedule.
Return Time: (military time)
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Now H:M Return hours are 8:30am-4pm M-F
Number of Rooms Required:
* must provide value
The Center will choose which room(s) based on availability. If an InSitu session, please type NONE.
Have you run this session before?
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Yes No
Please list dates/times that you can visit the Sim Center for a dry run of your scenario or orientation to the Simulation Center
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Instructor(s) Name(s):
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One instructor required per room requested. List NAMES.
Learners (check all that apply):
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Type of Group (check all that apply):
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If other, please specify:
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Is this a Continuing Medical Education (CME) session? Only applicable if attendees are being charged a fee for CME credit.
* must provide value
Yes
No
CME sessions require a meeting with the Sim Center, please list dates/times you would be available to meet.
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Total Number of Learners:
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Total Number in Group:
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Number of Groups per Session:
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Number of Learners per Group:
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Please list your learning objectives for this session.
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Do you require an Event Coordinator (runs/times event) or an Event Assistant (helps with transitions)?
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NONE Event Coordinator Event Assistant Both
Event Coordinator/Event Assistant usage may require an additional fee.
Are Standardized Patients and/or Ultrasound Models required for your session?
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NONE Standardized Patients Ultrasound Models Both
Standardized Patient/Ultrasound Model usage may require an additional fee.
Number of Standardized Patients required:
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Number of Standardized Patient exam rooms required:
* must provide value
If an InSitu session, please type NONE.
Specify Age Range of Standardized Patients requested:
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Specify Standardized Patient demographic requested (if not specific, type N/A):
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Yes
No
Will the you need a moulage person provided by the Simulation Center?
Yes
No
Please provide name of the person applying the moulage.
List any dress codes or appearance requirements for the Specialized Patients.
List any props required for the simulation.
Will the session recordings need to be saved for review?
(Recorded sessions are permanently deleted after 30 days if they are not saved.)
Yes
No
The session recording will be saved. Please provide multiple dates and times to view the recording at the Simulation Center.
Please List Per Date/Time Requested - number of Standardized Patients required:
* must provide value
Training Contact Phone Number:
Provide preferred dates/times for SP training:
Where will the Specialized Patient training occur?
Simulation Center Offsite Location
Provide location of offsite training:
Provide list of instructors/staff involved in the training:
Number of Ultrasound Models required:
* must provide value
Specify Ultrasound Model demographic requested (if not specific, type N/A):
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Please List Per Date/Time Requested - number of Ultrasound Models required:
* must provide value
Please List Per Date/Time Requested - number of Standardized Patients and Ultrasound Models required:
* must provide value
Specify how many of EACH per date/time.
Number of Ultrasound Model exam rooms required:
* must provide value
If an InSitu session, please type NONE.
Task Trainers
Please indicate the Task Trainer(s) you need for your session:
* must provide value
Quantity - ABG Wrist Trainer
* must provide value
Available Quantity: 4
Quantity - Adult CPR Torso
* must provide value
Available Quantity: 2
Quantity - Adult Heart Auscultation Trainer (SAM II)
* must provide value
Available Quantity: 1
Quantity - AED Trainer
* must provide value
Available Quantity: 1
Quantity - Airway Head (Adult)
* must provide value
Available Quantity: 5
Quantity - Airway Head Difficult (Adult)
Center Quantity: 1
Quantity - Airway Head Difficult (7-Sigma)
* must provide value
Center Quantity: 1
Quantity - Airway Head (for Blakemore insertion specifically)
* must provide value
Available Quantity: 2
Quantity - Airway Head (Child)
* must provide value
Available Quantity: 2
Quantity - Airway Head (Infant)
Available Quantity: 2
Quantity - Arterial Line Trainer (Automatic Pump/Ultrasoundable)
* must provide value
Available Quantity: 1
Quantity - Arterial Line Trainer (Manual Pump/Ultrasoundable)
* must provide value
Available Quantity: 2
Quantity - Arthrocentesis Knee Trainer
* must provide value
Available Quantity: 2
Quantity - Baby Anne (CPR only)
* must provide value
Available Quantity: 2
Quantity - Becky Trainer (Open abdominal cavity)
* must provide value
Available Quantity: 6
Quantity - Birthing Trainer (PROMPT)
* must provide value
Available Quantity: 2
Quantity - Central Line Trainer (Adult)
* must provide value
Available Quantity: 7
Quantity - Central/Femoral Line Trainer (Pediatric)
* must provide value
Available Quantity: 1
Quantity - Cric/Trach Trainer
* must provide value
Available Quantity: 3
Quantity - Delivery Trainer (OB Suzie)
* must provide value
Available Quantity: 3
Quantity - Femoral Line Trainer (Adult)
* must provide value
Available Quantity: 4
Quantity - FLS Box Trainer
* must provide value
Available Quantity: 6
Quantity - Foley Trainer (Female)
* must provide value
Available Quantity: 2
Quantity - Foley Trainer (Male)
* must provide value
Available Quantity: 2
Quantity - Human Anatomy Model (Skeleton)
* must provide value
Available Quantity: 1
Quantity - Hysteroscopy Trainer
* must provide value
Available Quantity: 1
Quantity - Infant Clinical Skills Trainer (TruBaby X)
* must provide value
Available Quantity: 1
Quantity - Infant/Peds IV Arm
* must provide value
Available Quantity: 1
Quantity - Injection Pad
* must provide value
Available Quantity: 4
Quantity - IUD Trainer
* must provide value
Available Quantity: 2
Quantity - IV Arm
* must provide value
Available Quantity: 7
Quantity - Lumbar Puncture (Adult)
* must provide value
Available Quantity: 5
Quantity - Lumbar Puncture (Adult/Ultrasoundable)
* must provide value
Available Quantity: 2
Quantity - Lumbar Puncture (Infant)
* must provide value
Available Quantity: 1
Quantity - Newborn Anne
* must provide value
Available Quantity: 2
Quantity - NG Tube Trainer (Larry)
* must provide value
Available Quantity: 2
Quantity - Paracentesis Trainer
* must provide value
Available Quantity: 2
Quantity - Adult/Peds Chest Tube Block
* must provide value
Available Quantity: 3
Quantity - Pelvic Trainer (Female)
* must provide value
Available Quantity: 4
Quantity - Perineal Repair Trainer
* must provide value
Available Quantity: 1
Quantity - Rectal Examination Trainer
* must provide value
Available Quantity: 1
Quantity - Shoulder IM Trainer
* must provide value
Available Quantity: 1
Quantity - Suture Kit
* must provide value
Available Quantity: 5
Quantity - Thoracentesis Trainer
* must provide value
Available Quantity: 2
Quantity - Trauma Child Trainer (Chest Tube/Cric)
* must provide value
Available Quantity: 1
Quantity - Trauma Man Trainer (Chest Tube/Cric)
* must provide value
Available Quantity: 2
High Fidelity Manikins/Simulators
Please indicate the types of Manikin(s) you need for your session(s):
* must provide value
Quantity - Pediatric HAL (5 YO)
* must provide value
Center Quantity: 2
Quantity - Sim Man 3G
* must provide value
Center Quantity: 4
Procedural Trainers and Medical Equipment
Please indicate the types of Procedural Trainer(s) and Equipment you need for your session(s):
* must provide value
Quantity - Code Cart (Adult)
* must provide value
Available Quantity: 2
Quantity - Code Cart (Pediatric)
* must provide value
Available Quantity: 1
Quantity - EZ-IO Power Driver
* must provide value
Available Quantity: 2
Quantity - Force Triad
* must provide value
Available Quantity: 1
Quantity - GI-Bronch Mentor
* must provide value
Available Quantity: 1
Quantity - Glidescope (Adult only)
* must provide value
Available Quantity: 1
Quantity - Glidescope (Adult/Peds)
* must provide value
Available Quantity: 1
Quantity - Neopuff
* must provide value
Available Quantity: 2
Quantity - ObGyn Rolling Lamp
* must provide value
Available Quantity: 2
Quantity - OtoSim
* must provide value
Available Quantity: 8
Quantity - Rhythm Generator Box
* must provide value
Available Quantity: 1
Quantity - Ultrasound Machine (Edge)
* must provide value
Available Quantity: 4
Quantity - Ultrasound Machine (PX)
* must provide value
Available Quantity: 1
Quantity - Ultrasound Machine (Turbo)
* must provide value
Available Quantity: 1
Quantity - Ultrasound Machine (NanoMaxx)
* must provide value
Available Quantity: 1
Quantity - Vimedix ObGyn Ultrasound Trainer
* must provide value
Available Quantity: 1
Quantity - Vimedix TEE Ultrasound Trainer
* must provide value
Available Quantity: 1
Quantity - Zoll Defibrillator (ALS)
* must provide value
Available Quantity: 2
Quantity - Zoll Defibrillator (Plus)
* must provide value
Available Quantity: 1
Technology
Please indicate the types of Technology you need for your session(s):
* must provide value
Technology Field Other
* must provide value
Technology Quantity - Laptop
* must provide value
Do you require the recorded session be kept longer than 30 days?
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Yes No
Recorded sessions are permanently deleted after 30 days if they are not saved.
The recorded session will be locked. Please contact the Sim Center to schedule a date/time to view the recorded session.
Technology Quantity - Technician to run scenario:
* must provide value
Technology Quantity - Projectors
* must provide value
Technology Quantity - Chairs
* must provide value
Technology Quantity - Tables
* must provide value
Does the session require more than one station per room?
* must provide value
Yes
No
If multiple stations are required, please indicate the number of stations needed for the session(s), then please indicate what materials/items are needed at each station
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2 Stations = Stations A and B
3 Stations = Stations A, B, and C
4 Stations = Stations A, B, C, and D
5 Stations = Stations A, B, C, D, and E
6 Stations = Stations A, B, C, D, E, and F
7 Stations = Stations A, B, C, D, E, F, and G
8 Stations = Stations A, B, C, D, E, F, G, and H
Do you require certain suture? If yes, please specify in the additional information section at the end of the request if you will be providing your own. Choose no if you will need the sim center to provide and specify what size is needed.
Yes
No
Please specify any additional / other types of supplies requested here (including procedural kits, disposables, etc.):
* must provide value
Please include any equipment that will be brought to the sim center:
* must provide value
If you feel it would be helpful, please use the space below to describe the setup required for this session.
Please describe the purpose of the photo/video shoot and how you plan to use the Center. **Photo/Video Shoots require a planning meeting. We will contact you to schedule.**
* must provide value
Please describe the purpose of your request and any additional information. (Including additional session dates/times, if applicable)
* must provide value
Reception requests may require an addition fee.
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Please upload / attach a document here.
If there is more than one file, please consolidate into one file.
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