Simulator and or Equipment Request Form

Instructions:

Fill in the form to request Simulator and or Equipment usage. When complete, press the submit button at the bottom of the form. You will receive a confirmation email back for the dates and times requested. The request for equipment or simulator must be submitted no later than one week prior to the date requested to ensure all equipment and supplies are available for the times requested.

Requestor Information:

Name:

Email:

Phone:

Simulator and or Equipment Request

Date:

Start Time:

End Time:

Simulator(s) needed:

Medium Fidelity - Chloe (full-body, feedback via a tablet for CPR, blood pressure validation)
Medium Fidelity - Michael (full-body, 1-year pediatric patient simulator)
Low Fidelity - Chloe (full body, no feedback)
N/A

IV Access Needed:

Yes
No

Task trainers needed

Airway Heads:

IV Arms:

Symbio:

AED :

ACLS/BLS feedback mannequins (Adult):

ACLS/BLS feedback mannequins (Infant):

If additional equipment or special equipment is needed but not listed above, please specify below.:

Simulator and or Equipment Request Form

Education & Research

Simulator and or Equipment Request Form

Instructions:

Requestor Information:

Simulator and or Equipment Request

Task trainers needed