Rural Health Innovation Collaborative

Transforming the Education of Current and Future Healthcare Professionals

Event Request

Please complete the following form for each event you would like to schedule at 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*

Have you ever facilitated simulation at the RHIC Simulation Center?*
Yes
No

Has the event you are requesting ever been completed at the RHIC Simulation Center?*
Yes
No

Additional educators assisting in the event

Number of learners participating in event*

Will all of your students be present in the Simulation Center at the same time or will they have a staggered schedule?*

Hours of Operation
Monday - Friday
8am - 4pm, simulations begin at 9
To the best of your ability, please include an explanation of the date(s) available for simulation.*

What time frame are you requesting? Include a start and end time if possible.*

Which Setting do you need? choose all that apply *
Hospital
Clinic
Skills Training
In Situ

Number of requested simulation rooms*

Number of requested control rooms*

Will your event require a classroom ?*
Yes
No

Does your event require debriefing session(s)?*
Yes
No

Does your event need recorded?*
Yes
No

Will your simulation require simulation manikins, Standardized Patients (actors), both, or neither?*

Does your event require any task trainers (IV arms, auscultation manikin, etc.)? If so, which ones?*

Please provide a brief summary of the requested event (Ex. diagnosis, complications, simulation flow).*

Please list your simulation objectives.*

Please include any materials you already have developed or used previously for the event.*