Equipment Loan Request

Please complete the following form indicating what equipment you are wanting to borrow from the Simulation Center. Submission of this form does NOT indicate that your request has been accepted. A member of the Simulation Center staff will contact you with confirmation of the event.
For more information or questions, please contact:

Laura Livingston, BSN, RN, CHSE Kailee Burdick, DNP, RN, CNE
Lead Clinical Simulation Specialist Clinical Simulation Specialist
Laura.Livingston@therhic.org Kailee.Burdick@therhic.org

Full Name*

Email Address*

Phone Number*

Organization*

Department*

Course Name and Number, if applicable

Additional educators assisting in the event

Number of learners participating in event*

Hours of Operation:
Monday - Friday 8am - 4pm
What date are you wanting to pickup the trainer(s)?*

What date will the trainer(s) be returned to the Sim Center?*

What trainers, and how many of each, are you wanting to borrow?*

Please provide a brief summary of training you are conducting.*

Are there any additional supplies that will be needed?*

I acknowledge that I have read, understand, and agree to abide by the following:

- Healthcare Simulation Standards of Best Practice® and the Healthcare Simulationist Code of Ethics. I commit to upholding these principles in all simulation-based activities to ensure integrity, professionalism, and the highest quality of education and patient safety.
- I accept full responsibility for the safe use, secure storage, and timely return of all borrowed simulation equipment by the designated return date.
- I acknowledge that any medical supplies provided by the RHIC are to be used solely for educational purposes, will be securely stored away from patient care areas, and will be promptly returned or properly disposed of as required. *

If you do not get an email receipt of request submission within the next few minutes, please resubmit your request or email laura.livingston@therhic.org

Rural Health Innovation Collaborative

Transforming the Education of Current and Future Healthcare Professionals

Equipment Loan Request