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    Simulation Resource Request Form

    This form must be completed for each request of use of Equipment, Funds, or Development Assistance from the Pediatric Simulation Center.  This helps us organize and prioritize requests.  Please contact us at pedsimulation@mcw.edu with any questions.  We look forward to working with you to develop your simulation projects.



    *Contact Name:

    *Contact Phone Number:

    *Contact e-mail address:

    *Person Responsible for Equipment: (must have completed appropriate training)

    *Primary Organization:

    *Department:

    *Division:

    Please complete the following information about your event:

    *Event Date(s)

    *Event Time(s)

    *Event Location

    *Event Title

    Short description of the event:

    Learning Objectives for this event:

    Please provide some information about your event participants:

    Please provide a short description of who your learners are
    (medical students, residents, fellows, physicians, nurses, etc.), their specialty area or year in training.

    		  

    How many learners to you expect from each learner group?

    		  

    *Do the learners have a basic understanding of the objectives (lecture, reading, etc.)?
     Yes No

    		  

    Specific content or other instructions:

    		  

    Short description of evaluation method:

    		  

    Please let us know what resources you would like to request:
    Note that we do not control booking for the STAR Center resources. Supplying that information here helps us have an understanding of the scope and plan for your event.  We can help work with you to reserve STAR Center resources or you can contact them directly at (414) 456-4646 or edalcour@mcw.edu.

     

    Pediatrics Simulation Center Space:
     Clinical Simulation Room (6 Rooms Available)
         Conference Simulation Room (2 Rooms Available)
     Computer_Lab (8 Stations)
         CCC Suite 430 Conference Room (Seats up to 12)

    Pediatric Simulation Center Equipment:

    High Fidelity Mannequin (SimBaby)
    Low Fidelity Mannequin
    Intubation Model-Infant
    Intubation Model-Child
    Pediatric Ear Model
    Hip Exam Model
    Other

    STAR Center Space (2nd floor of Medical Education Building) -- Note Stan and Pedi have their own rooms and do not require separate room reservation, however keep in mind where people will collect and debrief if you need extra space for this. STAR Center Space (2nd floor of Medical Education Building) -- Note Stan and Pedi have their own rooms and do not require separate room reservation, however keep in mind where people will collect and debrief if you need extra space for this.

    STAR Center Space:
     Large Procedure Room
         Simulation Room Rooms (15 Available)
         Small Conference Room (Seats up to 10)
         Large Conference Room (Seats up to 15)
     Break Room with Kitchen (Seats up to 10)
     

    STAR Center Equipment:
     Pedi
         Stan
         Harvey
         SimMan
     Other

    Staff Assistance:
     Development
         Presentation/Event Running
         Technical Support
     Standardized Patient Recruitment
     Other

    Please indicate anticipated event cost (Note this can only be used for events in the STAR Center where the primary learners are residents or fellows)

    Event Cost: