Simulation Activity Request

Unit / Department

Email address

Simulation need

Outcome metric that needs to be improved

(example: QHIP Measurement, Best Practice, patient safety metric, etc)

Simulation champion(s) from your department

This person or persons will need to attend facilitator training, collaborate with VLC staff to write curriculum and scenario, and be available for all simulations. Approximately 20 hours of work + simulation.

Which of the individuals listed is the primary point person?

Who is your leadership or committee champion?

Have any of these individuals utilized simulation before or worked with VLC in the past? *

Yes

Have any of these individuals completed a Simulation Faculty Training at the VLC? *

Yes

Timeframe for implementation

Please give a minimum of 6 weeks.

Number of learners anticipated for the event

Time allocated for each simulation session

The simulation activity includes the following disciplines (choose all that apply)

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Simulation Activity Request