Initial Simulation Request Form - School of Health Sciences

First Name*

Last Name*

Email*

Preferred Phone Number*

Have you used the SHS simulation suite before?*

Yes

No

Program*

Other Program

Course Acronym and Number*

Date of Simulation*

Start Time of Simulation*

End Time of the Simulation*

Proposed Location(s) (for Anatomage Table use, fill out other form)*

HSC 201 – Anatomage Suite (40 students)

HSC 203 – ICU

HSC 204 – L&D

HSC 205 – Debriefing / post conference room (12 students)

HSC 207 – Pre conference room (8 students)

HSC 208 – Med/Surg

HSC 209- Exam Room

HSC 210- Exam Room

Number of Students*

Type of Simulation*

List overall simulation objectives below*

Agreement statements, by checking beside each statement, you agree to:*

Cancelation well ahead of event date when possible.

Simulation Suite will be left in the condition and configuration in which they were found.

Simulators can only be utilized under the direction of staff/faculty who have been trained and are competent with simulator operation.

Use, recording, reviewing student videos will be conducted maintaining integrity of FERPA and Stockton University policies.

As we grow, your comments & feedback from both our instructors and our learners is extremely important. Instructor/Learner evaluation forms are located in room 205/post-conference room. Please fill these out at the end of each session and leave them on the desk bin. The simulation suite staff really appreciates your feedback.