simulation center ou-tulsa simulation request

Simulation Center OU-Tulsa Simulation Request

Simulation Center OU-Tulsa, 4502 E 41st Street, Tandy Education Center, Tulsa, OK 74135 (918) 660-3863 – [email protected]

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♦ Completing this form does not complete the process of scheduling and organizing your event. Only after you receive an email confirmation will your event be placed on the schedule.

♦ Scheduling windows are as follows: Fall Semester (Aug – Dec): Feb 2 to May 1; Spring Semester (Jan – May): May 2 to Oct 1; Summer Semester (June – July): Oct 2 to Feb 1.

♦ Simulation Center OU-Tulsa is an active learning facility. Due to high user volume, we are not able to guarantee support for non-learning activities within the center.

♦ If your event results in the publication of scholarly works, we ask that you give appropriate authorship to SCOUT staff.

Basic Simulation Event Information Today’s Date:

Simulation Event Title:

Faculty / Facilitator:

Contact Information: office phone: cell phone: email:

Requestor’s Name:

Contact Information: office phone: cell phone: email:

Brief Description of the event: *provide a copy of course syllabus when possible

New or Modified Event? (modified = repeat or change)

☐ New ☐ Modified, how?

Requested Date(s):

Time(s):

Frequency of Program? *list all dates above

☐ One Time ☐ Weekly ☐ Monthly ☐ Bi-monthly ☐ Quarterly ☐ Other:

Type of Simulation?

Case Scenarios Developed?



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Scenario Information Existing Scenario or Case?

If yes, name of scenario or case:

Estimated Simulation / Encounter Time: (e.g. 15 minutes, plus 5 mins SP feedback)

Group Debriefing?

If yes, method using:

Learner Demographics Number of learners on each date?

Overall total number of learners?

Learner’s Program? *for multiple use boxes below

Years of Study? Class Size?

Departments Benefiting? *check each department that will benefit from simulation College of Allied Health ☐ Occupational Therapy ☐ Physical Therapy ☐ Medical Imaging ☐ Other:

School of Community Medicine ☐ Emergency Medicine ☐ Family Medicine ☐ Geriatrics ☐ Internal Medicine ☐ OB/GYN ☐ Pediatrics ☐ Physician Assistant ☐ Psychiatry ☐ Surgery ☐ Other:

School of Social Work ☐ BSW students ☐ MSW students

Haruv USA ☐ Agency:

Other non-OU agency: Total # of attendees: *please include observers/supervisors, etc.



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Faculty and Staff Involved with Simulation *in addition to faculty/facilitator listed above

Name / Dept Role Email

Needs, Goals and Objectives, and Assessments Assessment of Needs

Professional Practice Gap Identified By: ☐ New Procedure ☐ Standard of Care ☐ External Requirements (AAMC, ACGME, JCAHO, OSHA) ☐ National Patient Safety Goals ☐ Research Findings ☐ Other:

Practice Gap/Educational Need Of: ☐ Knowledge ☐ Competence ☐ Performance ☐ Patient Outcomes

Prerequisite Knowledge: Describe the knowledge and skills that learners should have prior to the event.

Development of Goals and Objectives

Learning Goals:

Describe your learning goals for the event. These are broad, generalized and usually related to overall department, program, or unit goals.

Learning Objectives:

Describe what you expect learners to be able to know, do, or demonstrate upon training completion. Objectives connect the identified gap/need with the desired result.



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Assessment of Learners

Assessment Strategies

Indicate all the assessment methods you plan to use to determine the knowledge and skills the learners have gained from the curriculum program. (All data gathering can be performed by our learning management system.) ☐ Learner-generated Video (faculty video review) ☐ Direct (live) Observation (peer or faculty) ☐ Learner Survey: ☐ Pre-Encounter ☐ Post-Encounter ☐ Learner Documentation (note, etc): ☐ Pre-Encounter ☐ Post ☐ SP Evaluation: ☐ Checklist ☐ Narrative ☐ Verbal Feedback, by: Time allotted: ☐ Self-Evaluation Video Review: ☐ Checklist ☐ Narrative ☐ Video ☐ Other:

Resource and Equipment Needs

Supplies/ Props:

List any supplies or props you will need to have provided by the Simulation Center. Please included quantities (per learner or overall), sizes, and types. (ex. Gloves – 1/pair per student; Suture – Vicryl 4-0 – 1/student)

Rooms Requesting:

☐ Outpatient Exam Room, how many: ☐ Inpatient/ER Rooms, how many: ☐ Home Environment ☐ Interview, how many: ☐ Task Training Room (cap. 35) ☐ Educational Room (cap. 20) ☐ Debriefing Room #1 (cap. 14) ☐ Debriefing Room #2 (cap. 18) ☐ Meeting Room (cap. 12)

Simulators / Trainers

Requesting:

Whole-body manikins ☐ SimMan Essential ☐ Noelle Birthing Pediatrics Training ☐ LP Trainer ☐ Central Venous: Head/Nech, US ☐ Code Cart: defib & rhythm simulator ☐ Foley Catheterization

Airway ☐ Intubation Head, Adult ☐ Intubation Head, Infant ☐ Intubation Head, Neo

Other Procedures ☐ IV Arm ☐ Adult LP / Epidural ☐ Port & PICC Line access ☐ Ultrasound ☐ Other?

OB/GYN ☐ Sophie & Mom ☐ Pelvic Exam ☐ Suture Skin ☐ Knot Tying Kit☐ Biopsy ☐ Injection: shoulder, knee, ankle

simulation center ou-tulsa simulation request

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