HealthPartners Clinical Simulation
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HealthPartners Simulation Request Form
*
Indicates required field
Date and Time
*
Requester Contact Information
Name
*
First
Last
Phone Number
*
Email
*
Department Leader
Name
*
First
Last
Phone Number
*
Email
*
Department or Targeted Participants:
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Internal Medicine
Emergency Department
PACU
Nursing
OR
Mental Health
ICU
Other
Organization
*
Regions Hospital
HealthPartners Medical Clinics
HealthPartners Dental Clinics
Methodist Hospital
Lakeview Hospital
Hudson Hospital
Amery Hospital
Westfields Hospital
TRIA
Please list the designated project contact information:
Reason for Request
Briefly describe the problem:
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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:
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No
Yes
If Ongoing, Frequency Preferred:
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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:
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HealthPartners Clinical Simulation & Learning Center
In Situ
Other
Number of Participants Anticipated per session:
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1-5
6-10
11-20
21 +
*Class size may be limited due to space and COVID restrictions
Other: Please specify
*
If Ongoing, Course Content:
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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:
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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
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