Initial Activity Form
Initial Activity Form Number (Internal Use)
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Is this activity being held in the Simulation Center?
Activity Title
If "Other", Please Describe
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Activity Start Date
MM
/
DD
/
YYYY
Activity Start Time
Time
:
Activity Duration
Hrs
:
Min
:
Sec
Do you anticipate repeating this activity in the future?
If "Yes", please provide proposed dates
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Please provide at least 3 Learning Objectives
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Primary User Group *
Specialty *
Estimated Number of Participants
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Rooms Requested (select all applicable)
Number of Simulation Rooms? (if applicable)
Recording Required?
Will Participants be Assessed?
If "Yes", How?
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Requested Task Trainers (if applicable). List of Available Equipment can be found here: http://hsc.ghs.org/sim-center/resources/
If "Other", Describe...
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Full Body Simulators Needed? (if applicable)
Standardized Patients (Actors) Needed? (This will require additional training and fees may apply)
Disposable Supplies Requested? (Ex. Central Line kits, Sorba-Shields, IV Catheters, etc.)
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Course Director Name and Credentials? *
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Course Director Email *
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Course Director Phone *
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Course Director Completed Online Education Module on HealthStream?
Please list other course faculty Names, Credentials, and if they have completed the online education module (Ex. Bob Smith, BSN, Online module complete)
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