MIDWESTERN UNIVERSITY
CLINICAL SKILLS AND SIMULATION CENTER
DOWNERS GROVE CAMPUS
EVENT REQUEST FORM
SECTION I: Access and Operations
The Main Clinical Skills and Simulation Center (CSC) is located in Auditorium Hall on the Midwestern UniversityDowners Grove campus (555 N. 31st Street). Annex locations on campus: Alumni Hall.
The CSC is open Monday thru Friday 8:00am – 5:00pm. It is closed Saturday, Sunday and during all University
holidays. All rooms in the CSC are locked outside of regular hours of operation. Use of the facilities and
equipment outside of regular business hours must be pre-scheduled and is subject to staff and resource
availability. Any activities scheduled outside of regular business hours require presence of faculty/program
representatives.
Reservations- All activities serviced by or conducted in the CSC should be pre-scheduled. Room and
equipment reservations are made during the “block request period” for the quarter in question (12-13 weeks
prior to the start of a quarter). Reservations must be made for all Standardized Patient activities, simulation
encounters, classroom sessions, task training workshops, and/or practice labs serviced by or conducted in the
Clinical Skills and Simulation Center.
Reminder that any non-CSC space (ie: remote classrooms, lecture halls, etc) for an event must go through the
normal block scheduling process and/or requested through campus facilities.
Cancellations - Once a cancellation occurs, the Center reserves the right to rebook those resources for another
activity. Cancellations within 1 week of the activity OR in which staff/supplies/equipment has been confirmed
for an activity will be billed accordingly.
Required Forms - An event or equipment request form is required for all activities coordinated by the
CSC. This form should be emailed to ilsimcenter@midwestern.edu or hand delivered at least 6 weeks prior to
the event. The ERF must include finalized case demographics and proposed training dates. Incomplete forms
will not be considered valid. We ask that you work out all event details before submission.
Case Materials - Final case or event materials must be submitted at least 4 weeks in advance of the event. If
a case requires the Standardized Patient to portray pain, the Pain Portrayal Form should be included with case
materials. Reasonable changes may be made to cases, format, student schedules, and/or staff resources up to
7 days prior to an event. After this deadline, significant event alterations may not be accommodated.
Equipment - No equipment may be removed from the CSC without prior, written consent from either the
Center Director or University Executive office. All equipment is valuable and should be handled with the care
commensurate with its value. With this in mind, all faculty, staff and students must be trained on the
operational flow, proper use of and treatment of equipment as well as Center policy and procedures prior to
use of CSC resources.
Revised: 11/05/2013
Clinical Skills and Simulation Center – Event Request Form
SECTION II: General Event Information
Key Contact
Date(s) of Event [include make up and
remediation sessions in applicable]
Event Time(s)
Course number and Title
[ie: PPRA 1713 Pharmacotherapeutics VI]
Learners and quantity
[(ie: ILPA Class of 2012, #86]
Faculty/Facilitators/Proctors
[ie: ILSLP Faculty, #6]
Type of Event [mark all that apply]
Standardized patient
Simulation
Skills Lab
Faculty Presentation
Lecture
Prebrief/Debrief
Other ____________________________________
Description of event
A final roster of students will be required prior to event.
SP Training Date(s)/Time (s)/Location(s)
Simulation Dry Run Date/Time/Location
SECTION III: Event Resources
Room(s) – please mark all that apply for event:
AUD Exam Rooms 1-3
AUD Exam Rooms 4-6
AUD Exam Rooms 7-10
AUD Exam Rooms 11-13
AUD Viewing Room A (seats 13)
AUD Viewing Room B (seats 7)
AUD Classroom 403
AUD Classroom 405
AUD Classroom 446
AUD Classroom 448
Set up for Room(s):
AUD Sim Suite 1
AUD Sim Suite 2
AUD Sim Suite 3
AUD Sim Suite 4
AUD L& D Suite
AUD Mock Operating Room A
AUD Mock Operating Room B
AUD Surgical Scrub Room
AUD Multipurpose Lab
AUD North Conf Room 402
AUD South Conf Room 449
ALUMNI Exam Rooms 1-4
ALUMNI Exam Rooms 5-8
ALUMNI Viewing Room C (seats 8)
ALUMNI Classroom ____
Other _______________
Other _______________
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Clinical Skills and Simulation Center – Event Request Form
Standardized Patients - please include as much detail as possible to ensure proper hiring.
Total Quantity: _____
# needed for this
demographic
Age Range
M/F
Special Demographics/Notes **
Floor manager
Classroom monitor
Simulation Scenario Personnel or Family Member ______________________________
Other ______________________________
**If you have additional criteria related to the above SP demographics, please contact SP Coordinator directly.
Simulators
iStan
Lucina 25
Birthing
Flat Belly
PediaSim
Metiman 1240
Lucina 26
Birthing
Flat Belly
BabySim
Metiman 1241
Metiman 1242
Makeup/Moulage for Simulators or Standardized Patients
Please indicate any anticipated needs (please specify which case):
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Clinical Skills and Simulation Center – Event Request Form
Procedure/Skills Trainers (Enter the total # of each trainer requested trainer. # available is in parenthesis.)
LOW FIDELITY SIMULATORS
Student Auscultation Manikin (SAM)(1)
CARDIOVASCULAR
IV/Venipunture Arms (15)
Arterial Puncture Wrist (elec pump) (2)
AIRWAY/PULMONARY
Adult Intubation Heads (4)*
Child Airway Heads (2)*
Infant Airway Heads (4)*
Cricothyrotomy Trainer (1)
Arterial Puncture Wrist (manual pump) (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)
HEENT
Ear Models (6)
Eye Models (2)
NEURO
Lumbar Puncture Trainer (pending)
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)
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.
SECTION IV: Learning Space Format
Case(s) – please indicate each case being used in event.
Name of case
Previously
used
New
Final case materials must be submitted at least 4 weeks in advance of the event.
Using for
Remediation/
Back up
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Clinical Skills and Simulation Center – Event Request Form
Case Layout
Part
Description/Scoring/Weight
Standardized Patient checklist
Faculty checklist (FON)
Doorway chart (pre-encounter)
Student post encounter
Case or event evaluation
Peer evaluation
Self evaluation
Other
Additional information about case layout:
Anticipated Timing
Pre-encounter Case review length
Encounter length
Feedback length
Post-encounter length
Transition length
Breaks
Other
At workstation?
In classroom?
Automated Audio and Video
Video
Based on user action (ie: student login, SP checklist display, faculty checklist submit, etc)
Based on time (ie start at 8am, stop at 8:25am)
Customized by CSC based on event schedule and structure
Addl info:
Announcements
Script provided
Customized by CSC based on event schedule and structure
Explain optimal timing for announcements (include script if available):
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Clinical Skills and Simulation Center – Event Request Form
Learner Actions/Notifications
Action
Timing/Interval (i.e. 1 week prior, btw Jan 10
– 17, when notified by course coord)
Learners may request the date/time for their encounter
Randomly assign encounter times
Email learner the date/time of their encounter
Email reminder of date/time of encounter
Email when grades/reports/videos are available
Notify learners about Video Review Session(s)
Other _____________________________________________________________________________
We will use universal CSC templates for email notifications unless specific language provided.
SECTION V: Grading and Reporting
Grading
Electronic
Paper
Combination (explain: ____________________________________)
Designate Report(s) to be released to the students
Individual checklists
Other
SP checklist *
Grade Report (most common)**
Faculty checklist (FON) *
Performance Matrix (abbreviated grade
report)
Pre-encounter learner entry
Comments Report
Post-encounter learner entry
Performance Category
Self Evaluation entry
Peer Evaluation entry
Educational Prescription Report
Incorrect/Not Done techniques (Must use
Video
Full video
Peer Access
To individual
checklist
To video
CT/IT/ND question format on checklist to release this
report)
Estimated date of report release ______________________________________
Estimated duration reports will be released _____________________________
Anticipated video review session date and time _________________________ Mandatory?
Yes
*If releasing individual checklists, please designate format. Mark all that should be included:
Scores
Answer values
Correct answer for learners
SP name
Faculty name
**If releasing grade report, please designate format. Mark all that should be included:
Student score
Sections (required)
Performance Category
Class Average
Case totals
Comments
Standard Deviation
Event totals
Box plots
Display individual/case performance based on natural score (achieved score/achievable score)
Display individual/case performance based on percentage (use ____ decimals for percent value)
No
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Clinical Skills and Simulation Center – Event Request Form
Designate Case Item Analysis
No point biserial values displayed
Point biserial value for each answer for each item
Point biserial value for correct answer(s) based on _______ percentile of top learners
Designate Privacy
On Raw data export
Show learner names
Show unique learner ID
Show faculty
On Open Ended Question
Scoring
Do NOT show learner names
Show learner names
Show unique learner ID
On Case Evaluation On Group Performance
Anonymous
NOT anonymous
Show names
Show unique learner ID
Show performance
category name
Designate Performance Category (if being used)
Category
Criteria
Category Description
SECTION VI: Terms of Agreement
Any additional requests or information about your event:
__________________________________________________________________________________________
__________________________________________________________________________________________
The CSC is looking forward to the opportunity to facilitate your activity. Your signature below verifies your
understanding of and agreement to abide by all CSC operational policies, procedures, and timelines. It further
indicates your financial understanding that all wages, resources, and/or supplies used in conjunction with this
event will be charged back to the program, organization or group requested and/or using said services.
________________________________________
(Course Director/Event organizer)
____________________________________
(Dean/ Program Director/or other authorized person)
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