Mt. Sinai Skills and Simulation Center
Needs Assessment
Program Information
Program Contact Name:
Program Contact Phone:
Program Contact Email:
Billing Contact Name:
Billing Contact Phone:
Billing Contact Email:
Institution:
Department:
Program Title:
Program Date(s):
Frequency:
□ 1-Time □
Recurring
Number of Sessions per Date:
Number of Hours per
Session:
Instructor(s):
□ Yes
Request Planning Meeting:
□ No
Date:
Request Facility Tour:
□ Yes
□ No
Date:
Environment:
□ Mt. Sinai Skills and Simulation Center
[Please Specify]:
□ On Location (In-Situ)
Mt. Sinai Skills and Simulation Center Facility Requirements
□ Standardized Patient (SP) Core (8 Exam Rooms Available)
Number of Rooms
Needed:
□ Large Conference Room (Maximum Capacity: 30 People)
□ Medium Conference Room (Maximum Capacity: 15 People)
□ Food/Beverage
(Please Describe):
□ Office Supplies
(Please
Describe):
Learners (Please Check All That Apply)
□ Pre-Med
□ Medical Student Year:
□ Dental Student Year:
□ Nurse Student Year:
□ Nursing Type: □ NP
□ MD
□ Faculty
□ PA
□ PharmD
□ PhD
□ Fellow
□ PGY
□ EMT
□ Other
(Please
Specify):
Number of Learners per
Session:
Total Number of Learners:
□1□2□3□4
□1□2□3□4
□1□2□3□4
□ RN □ APN □ LPN □
CRNA
□
CNS
General Program Description
Purpose of Program: (Please Check All That Apply)
□ Assessment
□ Exam Prep
□ Quality Assurance
□ Remediation
□ Research
□ Training
□ Other
(Please Specify):
Program Goals:
1)
2)
3)
Program Objectives: [6 Core Competencies] (Please Check All That Apply)
□ Patient Care
□ Medical Knowledge
□ Practice-Based Learning & Improvement
□ Interpersonal & Communication Skills
□ Professionalism
□ System-Based Practice
Program Design:
□ Single Modality
□ Multi-Modality
□ Integrated/Hybrid
Simulation Modalities: (Please Check All That Apply)
□ Standardized Patients/Professionals (SP’s)
□ High-Fidelity Manikins
□ Task Trainers
□ Surgical Simulators
□ Micro Simulation/Avatars
Evaluation Tools/Metrics/Simulation Scenarios (Check all that apply):
□ Previously Developed
□ Needs Editing
□ Needs To Be Created
*If you selected more than one box , please explain:
Video/Audio Recording:
□ Yes
Video-On-Demand (VOD) Access:
□ No
□ Yes □ No
□ Faculty ONLY
□ Faculty and Learners
Request Feedback Summary Report:
□ Yes □ No
Once you have filled out this Needs Assessment please return it to the Mt. Sinai Skills and Simulation Center
by
Email, Fax or Postal Mail.
Email: casesimcenter@case.edu
Fax: (216) 368-2006
Postal Mail:
Mt. Sinai Skills and Simulation Center
Case Western Reserve University School of Medicine
1551 East 105th Street
Cleveland, OH 44106
If you have any questions please feel free to call the Mt. Sinai Skills and Simulation Center office at:
(216) 368-0064.
Thank You!
Simulators & Task Trainers
(Please Check All That Apply)
Equipment Description
Website:
Equipment
Number
Availabl
e
Airway Management/Resuscitation
Task Trainers and Equipment
□ Airway Management Trainer (Adult)
□ Airway Management Trainer (Infant)
□ Airway Management Trainer (Pediatric)
□ “Airway Larry” Airway Management Trainer (Adult)
□ “Little Anne Family” CPR Manikins
□ “Little Anne” CPR Training System
□ CPR Manikin (Adult)
□ CPR Manikin (Baby)
□ “Fat Old Fred” CPR Manikin
□ Choking Manikin (Infant)
□ Choking Manikin (Adolescent)
□ Choking Manikin (Obese)
□ Cricothyrotomy Trainer (Adult & Pediatric Insert)
□ GlideScope
□ Anesthesia Machine
2
2
1
2
2
1
4
4
2
1
1
1
2
1
1
High Fidelity Manikins
Human Patient Simulators
□ “iStan” Simulator
□ “Stan” Emergency Care Simulator (ECS)
□ “METIman” Simulator
□ “Ryan” BabySIM Simulator
1
1
1
1
Number
Needed
Surgical Simulators
□ LAP Mentor (Haptic)
□ LAP Mentor (Non-Haptic)
□ ANGIO Mentor Express (Haptic)
□ Trauma Man
Vascular Access/Injection Task Trainers
□ Central Venous Access Head/Neck, Upper Torso
(Ultrasound)
□ Central Line Man (Non-Ultrasound)
□ Femoral Line Man (Non-Ultrasound)
□ Thoracentesis Midscapular (Ultrasound)
□ Ultrasound Machine
□ Infusion/Injection Arm (Adult)
□ Venipuncture and Injection Training Arm (Adult)
□ IV Puncture Arm (Pediatric)
□ Advanced IV Hand
□ IV Arm (Infant)
□ IV Leg (Infant)
□ Nita Newborn
□ Arterial Puncture Arm (Adult)
□ Arterial Puncture Arm (Infant)
□ Injection Trainer
□ Injection Trainer (Elbow)
□ Injection Trainer (Hand & Wrist)
□ Injection Trainer (Shoulder)
□ Aspiration Trainer (Knee)
□ Lumbar Puncture Spinal Injection Trainer (Adult)
□ Lumbar Puncture Spinal Injection Trainer (Neonatal)
1
4
1
1
4
4
1
1
2
1
1
1
2
2
2
1
3
2
2
1
1
1
1
4
2
Misc. Skills Practice Task Trainers and Equipment
□ Chest Tube Manikin
□ Suture Practice Arm
□ Knot Tying Board
□ Catherization Trainer (Male)
□ Catherization Trainer (Female)
□ Prostate Exam Simulator
□ Prostate Exam Box Trainer
□ Testicular Exam Simulator
□ Testicular Exam Model
□ Gynecological Pelvic Simulator
□ “Eva” Gynecological Simulator
□ PROMPT Birthing Simulator With Force Monitoring
□ Fetal Monitoring/Labor Progress Simulator
□ Advanced Childbirth Simulator Maternal & Fetal Birthing Torso
□ Cervical Dilatation Module
□ IUD Demonstration Model
□ “Susie” Articulating Fetus
□ Strap-On Breasts
□ ALS Trauma Head
□ “Mr. Hurt Head” Trauma Trainer
□ Eye Retinopathy Trainer
□ Diagnostic Ear Trainer
□ “Naso Man” Nasogastric Intubation Model
□ EZ-IO Intraosseous Access Training System (Driver)
□ EZ-IO Intraosseous Access Training System (Needle) [15mm]
□ EZ-IO Intraosseous Access Training System (Needle) [25mm]
□ EZ-IO Intraosseous Access Training System (Needle) [45mm]
□ EZ-IO Training Bones - Humeral Head (Adult)
□ EZ-IO Training Bones - Distal Right Tibia (Adult)
□ EZ-IO Training Bones - Proximal Tibia (Adult)
2
10
10
2
2
4
2
2
2
3
1
2
1
1
1 Set
5
1
2
1
1
2
2
1
2
2
2
2
2
2
2
□ EZ-IO Training Bones - Tibia (Pediatric)
□ EZ-IO Training Bones - Tibia (Infant)
□ Auscultation Trainer and Smartscope
□ Lecat’s Ventriloscope
2
2
1
5
Moulage
□ Face-Head Injury
□ Open Head Wound
□ Degloved Hand
□ Burned Forearm
□ Fire Burns
□ Electrical Burns
□ Bruising Patches
□ Arm Amputation (Full)
□ Arm Amputation (Partial)
□ Leg Amputation (Full)
□ Leg Amputation (Partial)
□ Leg Impalement
□ Amputation
□ Compound Fracture of the Arm
□ Abdominal Evisceration
□ Calf Avulsion
□ Lacerated Thigh
□ Compound Fracture of the Tibia
□ Lacerations
□ Bullet Holes
□ Spider Ulcer
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1