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Schedule Request Form
Schedule Request Form
Full name
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…
Enter 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…
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How many standardized patients do you need?
Standardized patient arrival time
Standardized patient departure time
Manikin
SimMan 3G
SimMom
SimNewB (Newborn)
Nursing Kelly (3 available)
SimMan Essential (3 available)
SimJunior
SimBaby (3 month old)
Room preference
Acute Care
Labor & Delivery
Helicopter
Large Classroom
Critical Care
Ambulance
Aparrtment
Nurses Station
Other…
Enter 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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