Simulation Activity Leader or Owner Name
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First Name
Last Name
Simulation Activity Leader or Owner Email
*
Additional faculty or facilitator name
First Name
Last Name
Additional faculty or facilitator name 2
First Name
Last Name
Additional faculty or facilitator name 3
First Name
Last Name
Simulation learners
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What level and practice area of healthcare learners will be participating in this simulation session? Clearly understanding the experience level will help us determine the appropriate fidelity level for simulation training.
Expected number of learners per session
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Num sessions planned per year
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Length of session in hours
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Start Date
How urgent is this curriculum? Is there a date that the session must be run by?
MM
DD
YYYY
Simulation session description
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Describe the session in as much detail as you currently know. Will there be didactic lecture, video demonstration, facilitator demonstration, hands-on procedural skills stations, team-based scenarios, pre or post knowledge tests, assessments (we can help plan these), debriefing (again, we can help here), program evaluations? If you are running scenarios, will it be a custom one we need to program and test? Give as much details as you currently know. If there are things you would like to do, but are unsure, let us know that too and our simulation experts can help plan any elements of simulation-based education.
Education Elements
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Check all elements needed for the session.
Knowledge, Procedural, and Team-based Skills List
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Check all skills / procedures that will be taught, practiced, or assessed during the simulation session. The list may be long, especially for year-long curriculums. If any planned skills are not listed, select Other and describe in next field.
Instruments and Supplies
List any specific instruments or supplies needed. Be as detailed as possible.