Request a Simulation Activity This form must be completed at least 90 days prior to implementation of a new simulation course. Once submitted, a simulation center team member will reach out to you to set up a planning meeting. Type of simulation experience*Required - Select One - Standardized Patient Scenario-based Skills-based Scenario-based and skills-based together Vital Talk Other × Error: A field is missing data or special characters were used. Please correct. - Select One - SP Rooms Only Standardized Patients (SP) Test Proctor / Proctor Physical Exam Models × Error: A field is missing data or special characters were used. Please correct. - Select One - Manikin Standardize Patient Other × Error: A field is missing data or special characters were used. Please correct. - Select One - Animate Inanimate × Error: A field is missing data or special characters were used. Please correct. Please fill in other simulation experience × Error: A field is missing data or special characters were used. Please correct. Type of Vital Talks Activity - Select One - Vital Talk SPs (at Sim Center) Vital Talk SPs (offsite) × Error: A field is missing data or special characters were used. Please correct. Number of Standardized Patients (SP) Vital Talk × Error: A field is missing data or special characters were used. Please correct. Do you already have a case selected? Yes No × Error: A field is missing data or special characters were used. Please correct. Course Subtitle × Error: A field is missing data or special characters were used. Please correct. First name*Required × Error: A field is missing data or special characters were used. Please correct. Last name*Required × Error: A field is missing data or special characters were used. Please correct. Email address (you@someplace.com)*Required × Error: A field is missing data or special characters were used. Please correct. Office number (123-456-7890) × Error: A field is missing data or special characters were used. Please correct. Cell phone number (123-456-7890) × Error: A field is missing data or special characters were used. Please correct. Course director name*Required × Error: A field is missing data or special characters were used. Please correct. Course co-director name × Error: A field is missing data or special characters were used. Please correct. Learner affiliation - Select - UTSW Medical School UTSW Health Professions School UTSW Graduate Medical Education Health System Continued Medical Education Texas Health Resources Vendor Other × Error: A field is missing data or special characters were used. Please correct. Please fill in other learner affiliation × Error: A field is missing data or special characters were used. Please correct. Department or program*Required × Error: A field is missing data or special characters were used. Please correct. Is this a conference? *Required Yes No × Error: A field is missing data or special characters were used. Please correct. Will this simulation or project involve OR Black Box? *Required Yes No × Error: A field is missing data or special characters were used. Please correct. Will this simulation activity offer Continuing Medical Education (CME) or other Continuing Education (CE) credit? *Required Yes No × Error: A field is missing data or special characters were used. Please correct. Type of request New activity Previously hosted activity × Error: A field is missing data or special characters were used. Please correct. How will this activity be funded?*Required × Error: A field is missing data or special characters were used. Please correct. Learner Type*Required MS1 MS2 MS3 MS4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 PGY-6 PGY-7 PGY-8 Fellows Faculty Genetic Counseling Student Advanced Practice Providers (NP and PA) Registered Nurse Physician Assistant Student Practicing Healthcare Professional (Allied Health, RT, Clinical Nutrition, Social Worker) Other × Error: A field is missing data or special characters were used. Please correct. Please fill in other learners × Error: A field is missing data or special characters were used. Please correct. Course title × Error: A field is missing data or special characters were used. Please correct. Describe your ideal simulation experience in as much detail as possible. Please be aware finalized logistics will be discussed during your simulation planning meeting with UTSW Simulation Staff.*Required × Error: A field is missing data or special characters were used. Please correct. Preferred location*Required - Select One - Simulation Room with Manikin Simulation Room for Skills Only Simulation Exam Room (Outpatient/SP Area) Classroom Debrief (small group rooms) Other × Error: A field is missing data or special characters were used. Please correct. Please fill in other locations × Error: A field is missing data or special characters were used. Please correct. About how many learners will be attending?*Required × Error: A field is missing data or special characters were used. Please correct. How many facilitators/staff from your department/program will be assisting?*Required × Error: A field is missing data or special characters were used. Please correct. Preferred number of Clinical Simulation Program support staff. (This number is not guaranteed and subject to staff availability.)*Required × Error: A field is missing data or special characters were used. Please correct. Number and types of rooms requested (subject to availability)*Required × Error: A field is missing data or special characters were used. Please correct. Date requested: first preference*Required ×Please enter a date in the correct format (MM/DD/YYYY) Date requested: second preference*Required ×Please enter a date in the correct format (MM/DD/YYYY) Date requested: third preference*Required ×Please enter a date in the correct format (MM/DD/YYYY) List additional dates, if needed × Error: A field is missing data or special characters were used. Please correct. Time(s) requested*Required × Error: A field is missing data or special characters were used. Please correct. Estimated duration of your event*Required × Error: A field is missing data or special characters were used. Please correct. What medical equipment is needed (subject to availability)?*Required × Error: A field is missing data or special characters were used. Please correct. What audio visual support is needed? PowerPoints Presentations Recording Live viewing Other × Error: A field is missing data or special characters were used. Please correct. Does a national accrediting board provide these training methods? Yes No × Error: A field is missing data or special characters were used. Please correct. Goals: What should learners know or be able to do as a result of this event? × Error: A field is missing data or special characters were used. Please correct. Primary objectives × Error: A field is missing data or special characters were used. Please correct. Will there be an assessment? Yes No × Error: A field is missing data or special characters were used. Please correct. Will SP evaluate learners? Yes No × Error: A field is missing data or special characters were used. Please correct. Will SP provide feedback? Yes No × Error: A field is missing data or special characters were used. Please correct. Terms and conditions I understand that by selecting this box, I will ensure UTSW Simulation Center staff have appropriate case scenarios, agendas, number of learners and/or changes to the planned curriculum at least 30 business days before my scheduled event. Event is subject to cancellation per discretion of Simulation Center director upon failure to comply. *Required I accept the terms and conditions × Error: A field is missing data or special characters were used. Please correct. Consent to share your information I understand that by submitting this form, my information will be used to contact me regarding my interest in the UT Southwestern Simulation Program. I agree × Error: A field is missing data or special characters were used. Please correct. Activity Director Attestation for Scholarly Work The Sim Center encourages Activity Directors to pursue scholarly work based on their simulation activities to disseminate new science and innovation to others. By signing this attestation, I understand the requirement to include the Sim Center Acknowledgement Statement (below) on all presentations and publications related to my activities in the Sim Center. Further, I attest that I will provide the Sim Center Director, Dr. Daniel Scott, with a copy of all resulting publications at the time they become available online. By clicking this box and the Submit button, I agree to the these terms. × Error: A field is missing data or special characters were used. Please correct. Simulation Center Acknowledgement Statement The UT Southwestern Simulation Center Governance Committee requires that this statement is included in all presentations and manuscripts that involve scholarly activity work that was performed in the Simulation Center or supported by Simulation Center personnel, data, or physical resources. *Required
