Rural Simulation Center Request For
**This form is only a request.**
Your date is not confirmed until you see your course listed on the Calendar.
Name of Person and agency: *
Time Requested *
Please indicate what time you would like to use the SimCenter. The Center is open from 7am until 7pm Monday to Friday.
**Your date is not confirmed until you receive a confirmation and the date appears on the calendar**
Please check the Rural SimCenter calendar to be sure your dates are available.
Number of persons scheduled to attend *
Simulation Educator responsible for the session *
Requests must be made by and sessions run by qualified Rural SimCenter simulation educators
Use this space to communicate additional information about your simulation request.
For example, to avoid submitting identical requests for multiple dates, you can list all the dates here. Or you can put clarifying information in this space.
Please enter the e-mail addresses of educators you would like to receive course reminder information
Please indicate the mannequin(s) you plan to use for this educational session *
No Mannequins Required
SimMan 3G Laerdal
Preemie Hal Gaumard
Baby Hal Gaumard
Toddler Hal Gaumard
5yo Hal Gaumard
Noelle (Basic) Gaumard
Victoria (Advanced birthing Mannequin) Gaumard
Adult Hal Gaumard
VitalSim Baby Laerdal
VitalSim Kid Laerdal
I would like to request a standardized patient volunteer *
Please describe your standardized patient request. For example what age, gender, etc. is most appropriate for your scenario?
*Please note, requests for live actors should be sent at least 30 days before the event
Please list equipment needs from our standard list. *
No Equipment required-provided by educator
Headwall with Oxygen and Suction
Electronic Medical Record
Detailed List of Other Equipment Requested if needed.
Our equipment inventory is modest. If you have special equipment needs please call (530-332-5091) or email (firstname.lastname@example.org) to confirm the availability of equipment.
**If you require the use of consumable products such as dressings, IV tubing, medication vials, etc. Please contact us and plan to replace the products used.
Primary Contact e-mail *
Because scenarios require advanced planning and programming we require that the simulation scenarios that will be used for the scheduled session be submitted in the Rural SimCenter template at least 2 weeks in advance.
We only accept scenarios in the official Rural SimCenter template
. If you are unable to send your scenario in the Rural SimCenter template, please contact us.
If we do not receive your scenarios at least 2 weeks in advance your simulation time may be cancelled
* = Input is required
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