MIDWESTERN UNIVERSITY
CLINICAL SKILLS AND SIMULATION CENTER
GLENDALE CAMPUS
EQUIPMENT REQUEST FORM
SECTION I: Access and Operations
The Main Clinical Skills and Simulation Center (CSC) is located in Mesquite and Ocotillo Halls on the Midwestern University –Glendale campus. Center
hours are Monday – Friday between 8:00am and 5:00pm. The Center is closed Saturday, Sunday and during all University holidays. The CSC staff is
available during operational times by telephone or via email at azsimcenter@midwestern.edu . Center staff will respond to your inquiry within 2
business days.
Section II: Important Procedures
*Task Training Equipment reservations should be made at least 2 weeks in advance of the event. Verbal requests will not be authorized or
confirmed. Any email requests must be accompanied by this form. Indefinitely holding equipment without a scheduled event is prohibited.
* The Equipment Request Form can be emailed azsimcenter@midwestern.edu or hand delivered.
*If your Equipment Request includes use of Center space (Mesquite or Ocotillo Hall exam rooms), Standardized Patients, or Simulators, please use our
standard CSC Event Request Form.
*Equipment may NOT be checked out any sooner than 3 working days before the date of use unless otherwise authorized.
**Users are responsible for providing their own disposable medical equipment for use on any checked out equipment.
Section III: General Information regarding Request
Date of Request [at least 2 weeks prior to event]
Person making request [include phone #]
Date(s) and Time of Event
Course number and title [ie: PASS 0528
Advanced Physical Assessment]
Faculty/Facilitators/Proctors (responsible for
equipment and/or lab session)
Learners
[ie: AZCOM Class of 2014, Emed club]
Type of Event (mark all that apply)
LAB
LECTURE
ASSESSMENT
Description of event
Date/Time you anticipate pickup of equipment
Enter the total # of each requested trainer. Number available is in parenthesis.
HIGH FIDELITY SIMULATORS
iStan (2)
MetiMan (2)
Noelle Birthing Simulator (1)
Hal Neonatal Simulator (1)
PediaSim (1)
BabySim (1)
CARDIOVASCULAR
Arterial Puncture Trainer (4)
Blood Pressure Trainer (0)
Central Venous Cannulation Trainer (6)
Femoral Line Cannulation Trainer (4)
IV/Venipunture Arms (32)
NEURO
Adult Lumbar Puncture Trainer (4)
Pediatric Lumbar Puncture Trainer (2)
BONE/JOINT
Joint Injection (Shoulder) (2)
Joint Injection (Knee) (3)
MISCELLANEOUS
Hydroculator (1)
Paraphin Wax (1)
Therapeutic (non-image) Ultrasound (1)
Laparoscopy boxes (2)
AIRWAY/PULMONARY
Adult Intubation Heads (8)
Child Airway Heads (4)
Infant Airway Heads (4)
Laryngoscopes
Bag Valve Mask (Adult)
Bag Valve Mask (Pediatric)
Parecentesis/Thoracentesis Trainer (1)
Ultrasound Guided Chest Tube Trainer (4)
GASTROENTEROLOGY
Nasogastric Tube Trainer (cross-section) (4)
GENITOURINARY
Male Rectal/Prostate (7)
Female Pelvis (7)
Advanced Birthing Pelvis (3)
Female Catheterization (4)
Male Catheterization (4)
Urethral and superpubic male catheterization (2)
BREAST
Single Breast Model (with Path) (4)
Double Breast Model (2)
ADVANCED TECHNOLOGY
Sonosite Ultrasound with Transducers (1)
LapVR (Computerized Laparoscopy trainer) (1)
Section IV: Equipment Usage Agreement:
TERMS and CONDITIONS
The Clinical Skills and Simulation Center (and all equipment and space associated) serve as valuable educational and training resources for the
Midwestern University academic community. Therefore, respect for equipment, resources and scheduled activities is expected by all. The following
policies should be followed at all times:
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All equipment is valuable and will be handled with the care commensurate with its value;
Event organizers are responsible for clean up after their event. Rooms and equipment should be returned to their original state, unless otherwise
requested by CSC staff;
Equipment may only be checked out by faculty of Midwestern University upon completion of this agreement;
Faculty are expected to remain in designated lab areas and supervise the use of equipment for the entire course of authorized event;
No food or beverages will be allowed in the lab areas. Absolutely NO food or beverages are allowed near high-fidelity simulators. No exceptions;
Smoking is prohibited near equipment. Smoking is permitted outside of the facility and at a minimum of 25 feet away from all public entrances
and air intake ducts;
The high-fidelity simulators are simulating actual patients and deserve the safety precautions that would be taken with any live patient. Required
Safety interventions are as follows:
o Proper hand washing prior to care
o Treat the patient with respect and maintain privacy
o Always use two man transfers when moving the patient
o Physical safety of patient while in the bed to ensure no risk of injury or fall
o Avoid non-clinical sharp objects that could harm the patient
o No part of non-human or simulated patient should be removed or destroyed
The task training equipment is intended for multiple, repetitive use; however, safety precautions to ensure longevity of the trainers is requested.
Required Safety interventions are as follows:
o Proper hand washing prior to use
o Read any and all instructions before set up and use
o Use only CSC approved, designated lubricant, fluids, or needles with trainers
o Ensure stable counter, table or surface for use of trainers
o Avoid exposure to extremes of temperature
o Clean, Drain, and properly store models before returning
No equipment should be removed from campus without prior, written consent from either the Center Director or University Executive office;
If any simulation or task training equipment is not working properly, immediate notification should be made to CSC staff;
CERTIFICATION
The undersigned, in consideration of being allowed to use the CSC equipment: does hereby agree to indemnify, save and hold harmless Midwestern
University, and its officers, agents and employees, from and against any and all liabilities, claims, expenses, fees and costs, demands and actions, or causes
of actions whatsoever, for damage to personal property, personal injury or death which may result from the use of said equipment. Furthermore, the
undersigned promises to pay for any damage resulting from malicious or negligent use of equipment.
The undersigned promises to abide by the stated terms and conditions of this agreement and that any violation of these terms may result in immediate
revocation of equipment privileges.
___________day of ____________________________________, ______________
________________________________________
Signature
_____________________________________________
Print
Section V: Order Processing
Name/Signature
Order Prepared by:
Order Checked out by:
Order returned by:
Comments regarding equipment
[problems/ concerns]:
Repairs completed [if necessary]:
Date