Hill Rom Simulation Center

The Hill-Rom Simulation Center Event Request Form

Note: This form must be completed 6-8 weeks prior to requesting a simulation or OSCE. Please complete this form electronically and add detailed comments.

The amount of time and preplanning necessary for a simulation or OSCE event can vary, depending on the complexity of the event, available resources, existing demands, etc. Plan as far ahead to ensure a successful event.

Request Form

Course/Event Name

Today's Date

Name of Requestor

Phone

Position

Primary Email

Date(s) of Event

Start Time

End Time

Name of Case(s)

Has this case been used before?

Number of Facilitators

Have faculty attending been formally trained in simulation and debriefing techniques?

Number of Learners

How will the groups be rotating?

Number of Rotations

Amount of Time During the Rotations

Will this event be recorded?

Number of Standardized Patients

Number of GTA (Gynecological Teaching Associate)

Number of MUTA (Male Urological Teaching Associate)

Number of Skill Labs

Number of OSCE Exam Rooms

Number of Simulation Suites

Number of Debrief Rooms

Mannequins Requested

Equipment Requested

Equipment Furnished by Requestor

Disposable Supplies Needed

Number of Staff Requested

Briefly describe specific details related to this event not addressed above

Please note: You can expect contact from a simulation center staff within 1-3 business days. We are unable to accommodate event modifications within 5 days or fewer.

Thank you,
Hill-Rom Simulation Center Staff