DETAILED SETUP REQUEST FORM FOR ROOM [Enter Room #]
1st of 1 Room(s) Requested
Course: [Enter Course Name] Date: 1/4/2013 or Date Range: Enter text if necessary
Instructions: Check any/all request items that apply and click on “#” to select quantity if applicable
If Room [Enter Room #] setup varies each day or set of days, fill out a separate Setup Request Form for each variation.
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’)
Laerdal: ☐ SimMan ☐ SimBaby ☐ SimNewB ☐ SimJr ☐ SimMom ☐ ALS/SimPad ☐ SimMan 3G
Gaumard: ☐ Noelle
Other: ☐ Click here to enter text.
Please List ALL Scenarios Below:
OFFICE USE – LOGIN NAME: Click here to enter text.
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AUDIO/VISUAL EQUIPMENT REQUESTED – Must Choose One
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This course session will be video recorded. (NOTE: Participant release forms must be signed)
B-Line SimCapture will be used unless other is specified. Other: Click here to enter text.
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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 ☐ Other: Enter text here if applicable.
FURNISHINGS
☐ None Requested
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ROLLING EQUIPMENT
☐ None Requested
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)
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ER Stretcher (4 max)
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Hospital Gurney
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Ambulance Stretcher
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Maternal Delivery Bed (2 max)
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Other: Click here to enter text.
HEADWALL O2/VACUUM/Etc.
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O2 Flow Regulator (4 max)
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Vacuum Reg. & Canister (4 max)
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Other: Click here to enter text.
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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
Oxygen, Portable (5 max)
Storz Endoscopy Tower (2 max)
Glidescope w/Monitor
Ultrasonic Diagnostic Instrument
12-Lead ECG Monitor, Portable
Other: Click here to enter text.
Room Config. /Furnishing/Roll’g Eqpt. Instructions: Enter text here if applicable.
[Enter Course Name]
Rm [Enter Room #]
1 of 3
SIMULATORS (High & Med. Fidelity)
☐ None Requested
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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)
Noelle Matn’l w/Newborn (3 max)
Resusci Anne (2 max)
Harvey Cardiopulmonary (2 max)
Megacode Kid
SimJunior
SimMom w/Newborn (2 max)
Other: Click here to enter text.
MANIKINS (Med. and Low Fidelity)
☐ None Requested
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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.
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Simulator/Manikin Special Notes (e.g. positioning, wound types/locations, trachs): Enter text here if
applicable.
OFFICE USE ONLY: Click here to enter text.
COURSE-SPECIFIC SUPPLIES
☐ None Requested or Host-Provided
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Course host provides/sets up own items.
Number of containers: Enter quantity.
BEAM/Mod Sedation Kit
(2 containers)
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)
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DAM Kit (2 Containers)
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Defibrillator /Monitor, Zoll
Trauma Laproscopy (1 container)
ECCO (2 containers)
ED Trauma (1 container)
FOB (2 containers)
FLS (4 containers)
Golden Hour (2 containers)
MET Peds (2 containers)
OB Sim Lab (4 containers)
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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.
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Course/Medical Supplies Special Instructions: Enter text here if applicable.
OFFICE USE ONLY: Click here to enter text.
[Enter Course Name]
Rm [Enter Room #]
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ROOM [Enter Room #] TASK TRAINER(S) & ACCESSORIES REQUESTED FOR [Enter Course Name]
OB/GYN TRAINERS
AIRWAY MANAG’T TRAINERS - ADULT
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AIRWAY MANAG’T TRAINERS - PEDS
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Neonatal Intubation Tr. (max 3)
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Infant Airway Mgt. Trainer
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Pediatric Airway Mgt. Organizer
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Pediatric Intubation Trainer
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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
I.V. ART., INJ.&Etc. TRAINERS - ADULT
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# I.V. Arm – Adult (max 5)
# Arterial Stick Arm – Adult (max 2)
1 Vascular Access Trainer
1 Central Line Trainer – ‘Chester’
# Central Line U-sound Tr. (max 2)
1 Cut-down Ankle Venous Trainer
# CVC Insertion Trainer (max 3)
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Femoral Line Trainer (max 2)
Shoulder for Joint Injection
Lumbar Puncture Trainer
Spinal Injection (aka LP) Trainer
Peter PICC Line
Other: Click here to enter text.
1 OB Torso/Uterine Surgery Trainer
# Prompt Birthing Trainer (max 2)
66b
1 Hysteroscopy Trainer
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1 Female Pelvic Exam Trainer, Basic
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# Female Pelv. E.T., Adv. (Normal) (max 4)
66e
Female Pelvic E.T., Adv. Pathology Modules:
66eaA ☒ # Ovarian Cyst (max 2)
66eaB ☐ # Retroverted (max 2)
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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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FLS Laproscopic Trainer (max 4)
Ethicon Lap. Trainer (max 4)
Large Body Lap. Trainer
Other: Click here to enter text.
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☐ # Fibroid Cyst (max 2)
Other: Click here to enter text.
PHYS. EXAM TRAINERS/ANATOMY MODELS
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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
Small Heart Model (max 2)
Male and Female Anat. X-Section Model
Articulated Skeleton (max 2)
Other: Click here to enter text.
TRAUMA TRAINERS
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I.V. & I.O. TRAINERS - PEDIATRIC
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Trauma Man Thoracic Trainer (max 2)
Other: Click here to enter text.
URINARY CATHETER TRAINERS
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Female Catheter Trainer- Deluxe (max 2)
Male Catheter Trainer- Deluxe (max 2)
Female Catheter Trainer- Basic
Male Catheter Trainer - Basic
Other: Click here to enter text.
Trainer Notes: Click here to enter text if applicable.
OFFICE ONLY: Click here to enter text.
[Enter Course Name]
Rm [Enter Room #]
3 of 3