HealthPartners Simulation Activity Request - HealthPartners Clinical Simulation

HealthPartners Clinical Simulation

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HealthPartners Simulation Activity Request Form

* Indicates required field

Date *

Time *

Requester Contact Information

Name *

First

Last

Department Leader

Name *

Phone Number *

Email *

Department or targeted participants: *

Internal Medicine Emergency Department PACU Nursing OR Mental Health ICU Other

Activity Information

Title of Activity *

State the Objectives or Overall Goals *

Ongoing/Repeating: *

No Yes

If Ongoing, Frequency Preferred: *

Weekly Monthly Quarterly Yearly Other

Other: Please specify *

If Ongoing, Course Content: *

Continuous Content Changing Content

Repeating Content: The same scenarios/simulation activities are repeated at each session. Examples include: Medical Student Rescusitation Workshop, Managing Obstetrical Emergencies, Dental Simulations. Changing Content: New scenarios/simulaton activities occur with each session. Examples include EM Resident Small Group, IM Resident Mock Codes.

Length of Activity (i.e. 60 min, 4 hours) *

Month Preferred *

Day of the Week Preferred *

Time Preferred *

Activity Location: *

HealthPartners Clinical Simulation & Learning Center In Situ Other

Number of Participants Anticipated per session: *

1-5 6-10 11-20 21 +

Organization *

Regions Hospital HealthPartners Medical Clinics HealthPartners Dental Clinics Methodist Hospital Lakeview Hospital Hudson Hospital Amery Hospital Westfields Hospital TRIA

Which Department and/or Committee is supporting this activity? *

Please list the designated project contact information:

Name *

First

Last

Phone Number *

Email *

Reason for Request

What metrics will be used to determine the impact and/or effectiveness? *

What organizational priorities will this impact (i.e. Access & Flow, Patient Safety and Experience, Teamwork)? *

How will this activity improve patient safety? *

Equipment Request: *

Computer LCD Projector Mannequin Task Trainer Other

Other: Please specify *

Education Credit/Contact Hours Requested: *

None CNE CME Requester will Manage

Submit

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