MIDWESTERN UNIVERSITY
CLINICAL SKILLS AND SIMULATION CENTER
DOWNERS GROVE CAMPUS
EQUIPMENT REQUEST FORM
Important Procedures
*Task Training Equipment reservations should be made during block scheduling.
holding equipment without a scheduled event is prohibited.
Verbal requests will not be authorized or confirmed. Indefinitely
* The Equipment Request Form is due at least 2 weeks in advance of the resource needs and can be emailed to ilsimcenter@midwestern.edu or hand
delivered.
*If your Equipment Request includes use of Center space (Auditorium), 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.
General Information regarding Request
Date of Request [at least 2 weeks prior to event]
Person making request [include phone #]
Course number and title [ie: PASS 0528
Advanced Physical Assessment]
Learner Group and #
[ie: CCOM Class of 2014, FMED1702, #40]
Faculty/Facilitator/Proctor [responsible for
equipment and/or lab session]
Description of event
Location(s) equipment will be used
Date and approximate time for equipment
pickup or delivery
Date/Time of actual usage
Date and approximate time for return
Enter the total # of each requested trainer. Number available is in parenthesis.
HIGH FIDELITY SIMULATORS
iStan (1)
Metiman (3)
Lucina Maternal Fetal Simulator (2)
Birthing
Flat Belly
PediaSim (1)
BabySim (1)
LOW FIDELITY SIMULATORS
Student Auscultation Manikin (SAM)(1)
CARDIOVASCULAR
IV/Venipunture Arms (15)
Arterial Puncture Wrist Trainer (2)
Blood Pressure Trainer (7)
Blood Pressure Trainer w/IPOD Control(2)
Central Venous Access Trainer (4)
Femoral Line Access Trainer ( 4)
BONE/JOINT/SKIN
Infant Intraosseous Injection Trainer (1)
Joint Injection Trainer – Shoulder (3)
Joint Injection Trainer – Bent Knee (3)
Joint Injection Trainer – Wrist (3)
Joint Injection Trainer – Elbow (3)
IM/Digital Block/Local Anesthesia arms (5)
Ingrown Toenail Kit (4)
AIRWAY/PULMONARY
Adult Intubation Heads (4)*
Child Airway Heads (2)*
Infant Airway Heads (4)*
Cricothyrotomy Trainer (1)
Thoracentesis (Chest Tube) Trainer (1)
GENITOURINARY
ZACH multipurpose male trainer - NEW (8)
Male Catheterization trainer - OLD (8)
Prostate Trainer - OLD (2)
Gyn/Aid Gynecologic Trainer - NEW(8)
Birthing Trainer (2)
Pelvic Light Systems (13)
Female Catheterization (4)
BREAST
Single Breast Model (with pathology) (6)
Double Breast Model (4)
NEURO
Lumbar Puncture Trainer (pending)
HEENT
Ear Models (6)
Eye Models (2)
ADVANCED TECHNOLOGY
Sonosite Ultrasound with Transducers (4)
Electrocardiogram with cart (10)
LapVR (Computerized Laparoscopy Trainer)(1)
EndoVR (Computerized Endoscopy Trainer )(1)
NOTE: All fluids associated with model use will be supplied by the CSC.
*Each airway head comes with station kit including size appropriate laryngoscope, blades, airway adjuncts, BVM, etc.
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 or low 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 Always use two man transfers when moving the simulator
o Avoid non-clinical sharp objects that could harm the simulator
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 may 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 to CSC staff is requested;
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.
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Print Name
Signature
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Date
Order Processing
Name/Signature
Order Prepared :
Order checked out or delivered:
Order returned:
Comments regarding equipment
[problems/ concerns]:
Repairs completed [if necessary]:
Date