MIDWESTERN UNIVERSITY
CLINICAL SKILLS AND SIMULATION CENTER
Downers Grove Campus
OPTI PROGAM MODIFIED EVENT REQUEST FORM
SECTION I: Access and Operations
The Main Clinical Skills and Simulation Center (CSC) are located in Alumni and Redwood Halls on the
Midwestern University- Glendale. Our hours of operation are Monday – Thursday 8:00am - 4:30pm and Friday
8:00am – 12:00pm. We are closed Friday afternoon, Saturday, Sunday and during all University holidays. CSC
staff is available by telephone or via email at ilsimcenter@midwestern.edu . Center staff will respond to your
inquiry within 1 business days.
All activities at the CSC should be pre-scheduled. This includes equipment training or practice for faculty,
course development practice, course training for learners or standardized patients, assessments or testing,
meetings, tours, or any other activities. We will accept drop-in appointments, but cannot guarantee space or
equipment availability upon your arrival.
Important dates:
*Room and equipment reservations should be made at least 6 weeks in advance of the event. Verbal
requests will not be authorized or confirmed. Indefinitely holding rooms without a scheduled event is
prohibited.
* This OPTI Modified Event Request Form (ERF) must be emailed to ilsimcenter@midwestern.edu or hand
delivered at least 4 weeks in advance of the event.
*Final case or event materials must be received by center staff at least 3 weeks in advance of the event.
Changes to case materials, student schedules, and/or staff resources can be made up to 7 days prior to an
event. After this deadline, significant event alterations cannot be accommodated. If the CSC is unable to
accommodate the changes, rescheduling of the event may be required.
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: 11/10/2012
Clinical Skills and Simulation Center – Event Request Form
SECTION II: General Event Information
Key Contact:
Type/Location of Residency:
Learners and quantity:
(ie: PGY 1’s #8, PGY2’s #10)
# of expected Faculty/ Facilitators/ Proctors:
A final list of proctors is required 10 days prior
to event.
Request Date(s) of Event(s):
Requested Event Time (approx):
Type of Event (mark all that apply)
Standardized patient
Simulation
Skills Lab
Faculty Presentation
Lecture
Prebrief/Debrief
Other ____________________________________
Description of event
SECTION III: Event Resources
Room(s) – please mark all that apply for event:
AH = Alumni Hall; RH = Redwood Hall
AH Exam Rooms 1-4
AH Exam Rooms 5-8
RH Sim Bay #1
RH Sim Bay #2
Set up for Room(s):
AH Classroom
RH Classroom
RH Debrief Room
Other ___________________
Other ___________________
Other ___________________
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Clinical Skills and Simulation Center – Event Request Form
Standardized Patients
Qty
Case Name/Number (if applicable)
Age Range
M/F
Special Demographics/Notes
Floor manager
Classroom monitor
Simulation Scenario Personnel or Family Member ______________________________
Other ______________________________
SP Training Date/Time/Location:
We will automatically identify the type and quantity of back up SPs needed based on your event structure.
Please DO NOT include in this table.
**If you have additional criteria related to the above SP demographics, please provide addendum to this ERF.
Simulators
iStan
PediaSim
BabySim
Simulation Dry Run Date/Time/Location:
Makeup/Moulage for Simulators or Standardized Patients
Please indicate any anticipated needs:
Task Trainers
CRISIS MANIKINS
Adult Crisis Manikin (1)
Student Auscultation Manikin (1)
CARDIOVASCULAR
Arterial Puncture Trainer (2)
Blood Pressure Trainer (10)
Central Venous Cannulation Trainer (1)
IV/Venipunture Arms (15)
Femoral Line Cannulation Trainer ( 1 )
AIRWAY/PULMONARY
Adult Intubation Heads (8)
Child Airway Heads (2)
Infant Airway Heads (2)
Laryngoscopes
Bag Valve Mask (Adult)
Bag Valve Mask (Pediatric)
Cricothyrotomy Trainer (1)
Thoracentesis (Chest Tube) Trainer (1)
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Clinical Skills and Simulation Center – Event Request Form
BONE/JOINT
Intraosseous Injection Trainer (1)
Joint Injection (Shoulder) (3)
Joint Injection (Knee) (3)
NEURO
Lumbar Puncture Trainer (1)
HEENT
Ear Models (8)
Eye Models (2)
GENITOURINARY
Male Pelvis w/catheterization (8)
Prostate Trainer (4)
Female Pelvis (8)
Birthing Trainer (2)
Female Catheterization ( 2)
Pelvic Light Systems (10)
BREAST
Single Breast Model (with Path) (6)
Double Breast Model (4)
SECTION VI: Simulator/Learning Space Format
SCE (Simulated Clinical Encounters) Mark all that apply
CARDIOVASCULAR
Acute CHF with Pulmonary Edema
Acute Myocardial Infarction (multiple
versions; STEMI, IWMI, etc)
Angina with Arrest
ACLS protocols (multiple versions)
Thoracic Aortic Dissection
Malignant Hypertension
PULMONARY
Tension pneumothorax
COPD with Resp Failure
Severe young asthmatic
Pulmonary Embolism
Pneumonia with septic shock
MISCELLANEOUS
Anemia with acute diverticulitis
Anaphylaxis (Adult)
Heroin Overdose
Acute Renal Failure
TRAUMA
Splenic Rupture with pneumothorax (MVA)
Stab wound to the neck with
pneumothorax
Stab wound to the chest
Pelvic Fracture with hypovolemia
Bag Valve Mask (Adult)
Bag Valve Mask (Pediatric)
PEDS
Anaphylaxis (Child)
Poisoning
Asthma Exacerbation
Other
NEURO
Subdural hematoma
Meningitis
GASTROINTENSTINAL
Acute Abdomen (Rupture Peptic Ulcer)
Diabetic Hypovolemic Shock (GI bleed)
CUSTOM
Please consult with Center Director to coordinate customized scenarios and needs.
Scenario/Case Layout
Part
Standardized Patient checklist
Faculty checklist (FON)/SCE
Competency checklist
Teamwork/communication
checklist
Doorway chart (pre-encounter)
Description/Scoring/Weight
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Clinical Skills and Simulation Center – Event Request Form
Student post encounter
Case or event evaluation
Other
Additional information about case layout:
Schedule
Pre-encounter Case review length
Encounter length
Feedback length (if applicable)
Post-encounter debrief length
Transition length
Breaks
Other
Please use n/a if not included in the learner encounters for this event.
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:
Must include copy of the announcement script if NEW recordings are necessary.
Learner Actions/Notifications
Action
Timing/Interval (i.e. 1 week prior, b/w Jan
10 – 17, when notified by program contact)
Learners may request the 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
Other _____________________________________________________________________________
We will use universal CSC templates for email notifications unless specific language provided.
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Clinical Skills and Simulation Center – Event Request Form
SECTION V: Grading and Reporting
Grading
Electronic
Paper
Combination (explain: ____________________________________)
Other __________________________________________________________________________________
Designate Report(s) if any to be released to the students
Individual checklists
SP checklist
Faculty checklist (FON)
Pre-encounter learner data
Post-encounter learner data
Case evaluation results
Peer evaluation results
Other
Performance Matrix
Grade Report
Skill Report
Incorrect/Not Done techniques
Comments Report
Educational Prescription Report
Video
Full video
Only Audio
Estimated date of report release ______________________________________
Estimated duration reports will be released _____________________________
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.
________________________________________
(Key contact/Course Director/Event organizer)
_________________________________________
(Dean or Program Director when applicable)
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