Rural Simulation Center Request Form
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.
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 *
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
PediaSim Meti Corp
Baby Hal Gaumard
Preemie Hal Gaumard
Toddler Hal Gaumard
5yo Hal Gaumard
Noelle (Basic) Gaumard
Noelle (Advanced) Gaumard
VitalSim Baby Laerdal
VitalSim Kid Laerdal
I would like to request a standardized patient volunteer *
Please describe your standardized patient request.
*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.
Primary Contact e-mail *
Please attach your scenario template here. Or, if the templates are on file, please attach your educational plan and timeline. Completed scenario templates are due no later than 2 weeks prior to your simulation event.
Please attach any accompanying files (x-rays, labs, etc.) here. Your file size is limited to 200 kb
Additional files. Your filesize is limited to 200 kb
* = Input is required
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