HealthPartners Clinical Simulation
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Simulation Activity Request Form
Requester Contact Information
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Organization requesting this activity:
*
Phone Number
*
Please list the designated project contact information:
Name
*
First
Last
Reason for Request
Email
*
Briefly describe the problem:
*
Targeted Participants:
*
Internal Medicine
Emergency Department
PACU
Nursing
OR
Mental Health
ICU
Other
Other: Please specify
*
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?
*
Activity Information
Title of Activity
*
Length of Activity (i.e. 60 min, 4 hours)
*
State the Objectives or Overall Goals
*
Ongoing/Repeating:
*
No
Yes
If Ongoing, Frequency Preferred:
*
Weekly
Monthly
Quarterly
Yearly
Other
Month Preferred
*
January
February
March
April
May
June
July
August
September
October
November
December
Day of the Week Preferred
*
Monday
Tuesday
Wednesday
Thursday
Friday
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 +
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.
Other: Please specify
*
Equipment Request:
*
Computer
LCD Projector
Mannequin
Task Trainer
Other
Mannequin: Please specify type--i.e. adult, child, OB
*
Task Trainer: Please specify
*
Other: Please specify
*
Education Credit/Contact Hours Requested:
*
None
CNE
CME
Requester will Manage
Submit