Application for Medical Simulation Activity
Application process to reserve GCSI Medical Simulation lab rooms and equipment. This form will be recorded and calendar holds will be made in order to reserve rooms and equipment. Courses will be notified 30-45 days prior to sim date to confirm space for sim.
Email address *
Proposed Date(s) --- (mm/dd/yy) *
Your answer
Start Time *
Time
:
End Time *
Time
:
Medical Simulation Rooms
*Additional space on surgical side must be requested seperately
Rooms Required *
*Classroom 2 is owned by Medical side and accommodates a maximum of 25 people with tables/chairs. Additional classrooms require personal booking by instructors. If other classroom is available within 30-45 days, course will be notified.
*Classroom 2 is owned by Medical side and accommodates a maximum of 25 people with tables/chairs. Additional classrooms require personal booking by instructors. If other classroom is available within 30-45 days, course will be notified.
Trauma 1
Trauma 2
Patient 1
Patient 2
Patient 3
OR 1
OR 2
Classroom 2
Procedure Room
Medical
AV Technology Required *
Required
Is this course on DevelopU? *
Required
Catering (Meal/# of people) (N/A if no catering needed) *
Your answer
Activity Title and Brief Description *
Your answer
Participants (Level/# of learners/# of Instructors) *
Your answer
Equipment/Supplies Required
*OB Task Trainers need to be requested separately
Provided by GCSI
*All equipment available is listed in parentheses. You cannot request more than what value is in parentheses.
1
2
3
4
5
6
7
3G Manikin (x1) [HiFi, 360J shock, seizure, eye movement]
ALS Manikin (x1) [HiFi, 360J shock]
SimMan (x1) [HiFi, 200J shock]
SimMom (x2) [HiFi, 200J shock, seizure, birthing module]
SimJr (x1) [HiFi, 200J shock, seizure]
SimBaby (x1) [HiFi, 200J shock, seizure]
SimNewB (x1) [HiFi, 200J shock, seizure]
Chest Tube Trainer (x2)
Central Line Trainer (Ultrasound) (x2)
Central Line Trainer (Non-Ultrasound) (x2)
Lumbar Puncture Trainer (Adult) (x2)
Lumbar Puncture Trainer (Peds) (x1)
Arterial Line Trainer (x1)
Thoracentesis Trainer (x1)
IO Trainer (x2)
Sonosite US Machine (x2)
Airway Head (Adult) (x4)
Airway Head (Peds) (x4)
Glidescope (x2)
Patient Bed/Cart (x7)
Crash Cart (x3)
PERC Cart (x1)
BLS Adult Manikin (x3) (No CPR Feedback)
BLS Adult Manikin (x1) (CPR Feedback)
BLS Peds Manikin (x3) (No CPR Feedback)
Provided by Instructors
Your answer
Additional Comments/Requests
Your answer
Agreement Terms
All courses are required to use this form to request GCSI sim lab space and equipment. Failure to follow this application process will lead to no sim being done in the sim lab and no equipment being used. All Instructors are required to come down to lab the week of course or week prior to confirm space and setup provided by the GCSI team. All rooms and equipment in GCSI are a shared space and property, therefore all rooms and equipment must be treated safely and correctly. Rooms and equipment must be put back to where they were found when starting the course. Failure to do so will result in less sim permissions and/or ban from the GCSI sim lab. All additional requirements/ conditions must be emailed or called in to the GCSI team.
Do you agree to the GCSI terms and conditions? *
Required
Signature (Course Coordinator) *
Your answer
A copy of your responses will be emailed to the address you provided.
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