Rural Simulation Center Request Form
Name of Person and agency: *
Time Requested *
Number of persons scheduled to attend *
Simulation Educator responsible for the session *
Use this space to communicate additional information about your simulation request.
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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