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:

Kailee Burdick, DNP, RN, CNE
Clinical Simulation Specialist
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
Classroom

Number of requested simulation rooms*


Number of requested control rooms*


Does your event require debriefing session(s)?*
Yes
No, my event is skills training only

Will you debrief after each encounter or all together?

Does your event need recorded?*
Yes
No

Will your students need access to their recordings?
Yes
No

Please download and fill out this form and then attach it with the button below * UserImportForm.csv

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

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.
If you have downloaded the User Import Form, please attach that here as well.*

I acknowledge that I have read, understand, and agree to abide by the 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.*

Submit

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