MUSC SIMULATION CENTER COURSE REQUEST FORM
Instructions: Please provide the following info to use the Simulation Center for an Approved Activity and email to
simcenter@musc.edu. If your course has not been approved, please complete a New Course Development Form. This
form must be completed in its entirety to reserve space at the Simulation Center.
Department:
Division:
Course Title:
Course Director:
Course Description:
Facilitators:
Participant Type:
# of Attendees:
Dept. Contact:
Email & Phone:
Responsible
Funding Center:
Participant Category
Participant Type
☐MUHA Staff
☐Clinical Nurse
☐Faculty
☐Hospital Staff
☐Residents
☐Medical Faculty
☐ CON
☐Students
☐Dietetic Intern
☐ COP
☐Other
☐Physician
☐ MUHA
☐ COM
☐ CHP
☐Inter-professional
☐ CDM
☐Other
Approved by:
(print)
Signature:
FOR MUSC SIMULATION CENTER USE ONLY:
Received Date:
☐ Approved
Sim Spec Review by:
☐ Approved w/modifications (see notes)
Admin Review by:
☐ Denied
DATE(S) AND TIMES REQUESTED
Date 1: Click here to enter a date.
Start & End Times: Click here to enter text.
Date 2: Click here to enter a date.
Start & End Times: Click here to enter text.
Date 3: Click here to enter a date.
Start & End Times: Click here to enter text.
Date 4: Click here to enter a date.
Start & End Times: Click here to enter text.
Date 5: Click here to enter a date.
Start & End Times: Click here to enter text.
TOTAL No. OF ROOMS REQUESTED: Select #
ROOM(S) REQUESTED FOR THIS COURSE (Check all that apply)
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SN102
SN104
SN102/4
SN110
SN113
SN103
SN106
SN107
SN106/7
‘Classroom’ -capacity 20
‘Classroom’ -capacity 20
‘Large Classroom’ -capacity 40
‘Debrief’ - capacity 6
‘Conference Room’ -capacity 10
‘ER' -4 beds/capacity 15
‘Patient Rm' -3 beds/capacity 8
‘Patient Rm' -3 beds/capacity 8
‘Patient Rm' -6 beds/capacity 16
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SN108
SN114
SN116
SN118
SN121
SN122
SN123
SN124
SN125
‘Labor & Delivery’ / Pt.-2 beds/cap. 8
‘OR' -1 bed / capacity 8
‘Patient' -1 bed/ capacity 6
‘Labor & Delivery’ / Pt. - 1 bed /cap. 6
‘Patient' -1 bed/ capacity 6
‘Exam / Trainer' - 1 bed/ capacity 6
‘Exam / Trainer' - 1 bed/ capacity 6
‘Exam / Trainer' - 1 bed/ capacity 6
‘Exam / Trainer' - 1 bed/ capacity 6
Notes: Rooms SN103, SN106/107, SN114, SN115, SN118, SN121, SN122, SN123, SN124, SN125 all have auxiliary
Control/Viewing Rooms. These associated rooms are included with your room request(s). Room changes due to scheduling
constraints may be made at the discretion of the Simulation Center.
ROOM CONFIGURATION REQUEST – Must Choose One
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Room Only (standard configuration, no additional furnishing or equip’t –see room descriptions)
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Room in standard config. with addt’l items or substitutions as indicated in sections following:
COMPUTER AND PRESENTATION EQUIPMENT REQUESTED – Select Any that Apply
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Laptop Computers (max 20) – Quantity: Click here to enter quantity.
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Access to / Screen Display of internet or other media ☐ Other: Click here to enter text.
SOFTWARE/SCENARIOS USED - Must Choose One Min.
☐ No Scenarios (including ‘Healthy Patient’)
System: ☐ Legacy ☐ LLEAP ☐ SimPad Only ☐ Other: Enter text here.
For Simulator(s): ☐ SimMan ☐ ALS ☐ SimMan 3G ☐ SimMom ☐ SimJr ☐ SimBaby ☐ SimNewB
☐ Resusci-Anne Other: ☐ Click here to enter text.
List all Scenario Names Below:
1
2
3
Enter text here.
Enter text here.
Enter text here.
OFFICE USE ONLY
6
7
8
Enter text here.
Enter text here.
Enter text here.
AUDIO/VISUAL EQUIPMENT REQUESTED – Must Choose One
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This course session will be video recorded w/ B-Line SimCapture OR other: Enter text here.
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This course session will not be video recorded.
PERSONNEL REQUESTED - Select Any that Apply
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Simulation Specialist
☐ I.T. Support
Form Rev. 9/22/14
☐ Other: Enter text here.
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FURNISHINGS
☐ None Requested
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31j
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Extra Chairs: Click to enter quantity.
Extra Tables: Click to enter quantity.
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Exam Stool (6 max)
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Exam Lamp – Gooseneck (3 max)
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Hospital Bed (max 6; in SN106/107)
#
ER Stretcher (4 max)
1
Hospital Gurney
1
Ambulance Stretcher
#
Maternal Delivery Bed (2 max)
#
Other: Click here to enter text.
HEADWALL O2/VACUUM/Etc.
#
O2 Flow Regulator (4 max)
31k
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Vacuum Reg. & Canister (4 max)
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#
Other: Click here to enter text.
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31b
31c
31d
31e
31f
31g
31h
31i
ROLLING EQUIPMENT
☐ None Requested
32a
32b
32c
32d
32e
32f
32g
32h1
32h2
32i
32j
32k
32l
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1
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Anesthesia Cart (3 max)
Crash Cart w Portable Vac (3 max)
IV Poles (5 max)
Alaris Pump (3 max)
Kangaroo Pump
BP monitor,portable (2 max)
Neonatal Isolette - Wood
Neonatal Incubator – Metal, Open
Neonatal Incubator – Enclosed
Oxygen, Portable (5 max)
Storz Endoscopy Tower (2 max)
Video Laryngoscope with Monitor(2 max)
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1
12-Lead ECG Monitor, Portable
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#
Other: Click here to enter text.
Room Config. /Furnish’g/Roll’g Eqpt. Instructions: Enter text here.
SIMULATORS (High & Med. Fidelity)
☒ None Requested
41a
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1
41b
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#
41c
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41d
41e
41f
41g
41h
41i
1
1
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SimMan 3G – Mod Sed. Pref’d
Gender : Choose gender.
SimMan (8 max)
☒ Unisex/No Preference OR
# of Males: Quantity.
# of Females: Quantity.
SimBaby (2 max)
SimNewB (2 max)
SimMom w/Newborn (2 max)
Resusci Anne (2 max)
Harvey Cardiopulmonary (2 max)
Megacode Kid
SimJunior
Other: Click here to enter text.
Other: Click here to enter text.
MANIKINS (Med. and Low Fidelity)
☒ None Requested
42a
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42b
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42c
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ALS Manikin (Med. Fidelity) (3 max)
Gender : Choose gender distribution
Adult Manikin (Low Fidelity) (3 max)
Std configuration: 1 has all limbs, 1 w/
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amp. arm @elbow , 1 w/amp. low leg
Gender : Choose gender distribution
# ALS Baby (Medium Fidelity) (2 max)
1 BLS Baby (Medium Fidelity)
# Other: Click here to enter text.
# Other: Click here to enter text.
SIMULATOR / MANIKIN ACCESSORIES
Nuclear Biological Chemical Modules
Simulator/Manikin Trauma Limb(s)
# Other: Click here to enter text.
# Other: Click here to enter text.
#
Simulator/Manikin Special Notes (e.g. positioning, wound types/locations, trachs): Click here to enter text.
Form Rev. 9/22/14
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COURSE-SPECIFIC SUPPLIES
☒ None Requested or Host-Provided
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51b
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51c
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51d
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51e
51f
51g
51h
51i
51j
51k
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Course host provides/sets up own items.
Number of containers:
Mod Sedation Kit
(1 container = 2 stations)
BEAM/DAM Kit (1 container = 1 station)
Quantity. ( 4 Max Kits)
Trauma (1 container)
ECCO (2 containers = 1 station)
ED Trauma (1 container)
FOB (1 container = 2 stations)
FLS (4 containers = 1 course / 4 stations)
Golden Hour (2 containers = 1 station)
MET Peds (2 containers = 1 station)
OB Sim Lab (4 containers = all scenarios)
MEDICAL SUPPLIES & EQPT REQUESTED
☒ None Requested
Airway Kit, Advanced: (OPA’s, ETT’s,
LMA’s, Laryngoscope & Blades, etc.)
Airway Kit, Basic: (1 BVM, 1 Facemask, 1
Non-Rebreather, 1 Nasal Can., 1 O2 Line)
52a
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52b
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52c
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1
Defibrillator /Monitor, Zoll
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1
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Defibrillator /Monitor, Zoll – Non-pacing
Defibrillator /Monitor, LifePak 12 (2 max)
Defibrillator /Monitor, LifePak 20 (2 max)
EKG Leads -- ☒ Faux ☐ Functional
C-Spine Backboard & Neckbrace (3 max)
CVC Kit
Lumbar Puncture Kit
NG Tube Kit
Drapes, Specify: Enter text.
52d
52e
52f
52g
52h
52i
52j
Other: Click here to enter text.
Other: Click here to enter text.
Other: Click here to enter text.
Other: Click here to enter text.
Other: Click here to enter text.
Course/Medical Supplies Special Instructions: Enter text here.
ROOM TASK TRAINER(S) & ACCESSORIES REQUESTED FOR [Enter Name]
☐ No Sim Center Trainers Requested
☐ Host Will Provide Trainers: Click here to enter text.
☐ See Selected Items Below (Check all that apply, click “#” to select quantity)
AIRWAY MANAG’T TRAINERS - ADULT
61a
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61c
61d
61e
62a
62b
62c
62d
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AIRWAY MANAG’T TRAINERS - PEDS
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Neonatal Intubation Tr. (max 3)
1
Infant Airway Mgt. Trainer
1
Pediatric Airway Mgt. Organizer
1
Pediatric Intubation Trainer
#
Other: Click here to enter text.
Trach Trainer – Head & Shoulders
Airway Trainer – FOB (max 2)
Airway Trainer – NG Tube /Trach
optimized (max 3)
Active Servo Lung 5000
Intubation Trainer – Cross Section
Form Rev. 9/22/14
URINARY CATHETER TRAINERS
69a
69b
69c
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69d
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Female Catheter Trainer- Deluxe (max 2)
Male Catheter Trainer- Deluxe (max 2)
1
1
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Female Catheter Trainer- Basic
Male Catheter Trainer - Basic
Other: Click here to enter text.
TRAUMA TRAINERS
68a
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Trauma Man Thoracic Trainer (max 2)
Other: Click here to enter text.
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I.V. ART., INJ.&Etc. TRAINERS - ADULT
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63h
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63a
63b
63c
63d
63j
63k
63l
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I.V. Arm – Adult (max 5)
Arterial Stick Arm – Adult
Vascular Access Trainer
Central Line Trainer – ‘Chester’
Central Line U-sound Tr. (max 2)
Cut-down Ankle Venous Trainer
CVC Insertion Trainer (max 3)
Femoral Line Trainer (max 2)
Shoulder for Joint Injection
1
1 Lumbar Puncture Trainer
1 Spinal Injection (aka LP) Trainer
1 Peter PICC Line
# Other: Click here to enter text.
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I.V. & I.O. TRAINERS - PEDIATRIC
64a
64b
64c
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PHYS. EXAM TRAINERS/ANATOMY MODELS
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67c
67d
67e
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67g
67h
67i
67j
67k
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Ear Exam Simulator
Eye Retinopathy Trainer
Knee for Aspiration
Breast Exam Trainer (max 3)
BSE Fiberocystic Model
Rectal/Prostate Exam Trainer
Testicular Exam Trainer
Large Heart Model (max 2)
Small Heart Model (max 2)
Male and Female Anat. X-Section Model
Articulated Skeleton (max 2)
Other: Click here to enter text.
Trainer Notes: Click here to enter text.
OFFICE ONLY: Click here to enter text.
I.V. Arm – Pediatric (max 2)
Intraosseus Leg – Pediatric (max 2)
Baby STap Lumbar Trainer (max 2)
Other: Click here to enter text.
LAPROSCOPIC TRAINERS
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65b ☐
65c ☐
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FLS Laproscopic Trainer (max 4)
Ethicon Lap. Trainer (max 4)
Large Body Lap. Trainer
Other: Click here to enter text.
OB/GYN TRAINERS
66a
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66b ☐
66c ☐
66d ☐
1
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1
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OB Torso/Uterine Surgery Trainer
Prompt Birthing Trainer (max 2)
Hysteroscopy Trainer
Female Pelvic Exam Trainer, Basic
Female Pelv. E.T., Adv. (Normal) (max
66e
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Female Pelvic E.T., Adv. Pathology
Modules:
66eaA ☐ # Ovarian Cyst (max 2)
66eaB ☐ # Retroverted (max 2)
66eaC ☐ # Fibroid Cyst (max 2)
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Other: Click here to enter text.
Form Rev. 9/22/14
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