We are excited to serve you and your participants!

Please complete the following form for each event you would like to schedule at the Simulation Center. Submission of this form does NOT indicate that your request has been accepted. A member of the Sim Center Staff will contact you with more information and confirmation of the event. Each question assists the team in determining the possibility of scheduling your event. Please complete the form to the best of your ability. If this is your first time scheduling a simulation or if the simulation you are requesting is new, please complete the form and schedule a planning meeting.

For more information or to schedule a meeting, please contact:

Cary Stewart, BSN, RN

Clinical Simulation Specialist

Standardized Patient Coordinator

812-238-4818

cary.stewart@therhic.org

EVENT REQUEST FORM

Have you ever facilitated simulation at the RHIC Simulation Center? *

Yes No

Has the event you are requesting ever been completed at the RHIC Simulation Center? *

Yes No

Contact Name *

Organization *

Department *

Course Name and Number *

Email Address *

Phone Number *

Additional educators assisting in the event

Number of learners participating in event *

Will all of your students be present in the Simulation Center at the same time or will they have a staggered schedule? *

Normal hours of operation are M-F, 8-4, with simulation beginning at 9. Any request outside of this time can be discussed. To the best of your ability, please include an explanation of the date(s) available for simulation and the time frame you are requesting, including a start time and end time. *

Number of requested simulation rooms *

Number of requested control rooms *

Number of requested debriefing rooms *

Will your event require the classroom (events with >12 participants present at the same time)? *

Yes No

Does your event need recorded? *

Yes No

Will your simulation require simulation manikins, Standardized Patients (actors), both, or neither? *

How many simulation manikins will your event require?

Does your event require any task trainers (IV arms, auscultation manikin, etc.)? If so, which ones? *

Please provide a brief summary of the requested event (Ex. diagnosis, complications, simulation flow). *

Please list your simulation objectives. *

Please include any materials you already have developed for the event.

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Additional File 2

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The RHIC

Rural Health Innovation Collaborative

1606 N 7th Street

Terre Haute, IN 47804

(812) 238-4625

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RHIC Simulation Center Event Request Form

We are excited to serve you and your participants!

EVENT REQUEST FORM

The RHIC

Blogs