Schedule Request Form

First name

Last

Email address

Facilator name

Date of simulation

Start time

End time

Number of students

What time does the room need to be available to you for setup?

Scenario programming

Scenario to be protrammed by the Central Virginia Center for Simulation and Virtual Learning staff

Name of scenario used previously

Other…

Simulation operator name

Account

Centra (Hospital based)

Centra College of Nursing

Centra Family Practice Residency

Central Virginia Community College

University of Lynchburg (Nursing)

University of Lynchburg (DPT Program)

Other…

How many standardized patients do you need?

Standardized patient arrival time

Standardized patient departure time

Room preference

Acute Care

Labor & Delivery

Helicopter

Large Classroom

Critical Care

Ambulance

Apartment

Nurses Station

Other…

Number of debrief rooms

None

Debrief room (seats 12, 2 available)

Debrief room (seats 8, 6 available)

Large classroom (seats 48)

Please list all non-disposable equipment needed (e.g. ventilator, glucometer, etc.)

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