Activity Request - Augusta University Interdisciplinary Simulation Center

Simulation Activity Request Form

This form is required for all simulation, clinical skills, and skills lab requests.
Instructions:

Complete this form in its entirety, filling all applicable and required fields.

Important: If you have previously submitted a request for the activity in question please use the 'edit submission' link provided at the top of your submission confirmation email. Use this link to submit all changes. Changes are accepted until 2 weeks prior to the event date.

Upon submission of your scenario development form you will receive a case ID number to identify your case on this form.
Activity or Course Name
(This is how your activity will be referenced on the ISC calendar)
Course Number
(If applicable)
Program Name
College or Organization
Contact Information
- Primary Contact Name
  
  First NameLast Name
- Primary Contact Phone Number
  
  Area CodePhone Number
- Primary Contact Email
  example@augusta.edu
- Note: The primary contact will receive the submission confirmation email upon submission of this form and all subsequent booking confirmations. The primary contact will also be cc'ed on all billing related communications sent to the budget contact.
- Secondary Contact Name
  
  First NameLast Name
- Secondary Contact Phone Number
  
  Area CodePhone Number
- Secondary Contact Email
  example@augusta.edu
- Budget Contact Name
  
  First NameLast Name
- Budget Contact Phone Number
  
  Area CodePhone Number
- Budget Contact Email
  example@augusta.edu
- Participant and Faculty Information
- Participant Type
  Select all which apply. Ctrl + Click for multiples.
- Number of Participants
- Number of Faculty
- Interprofessional Opportunities
  Include any interprofessional opportunities here with contact and other information.
- Services and Items Selection
- Select all services or items required for your activity:
- Date Selection
  
  Please enter dates OR upload spreadsheet below
- Select One:
- Please Enter All Dates and Times Requested Below
- Click Here to Download the Spreadsheet for Dates and Rooms
  
  (Opens in a Google Document in a new tab, this page remains in background)
  
  Please download, fill out, and upload completed document below. If you choose to upload instead of filling the form, only this completed document will be accepted for requests.
- Upload Spreadsheet
  
  Browse Files
  
  Cancelof

Room Selection
Select One:
Classroom
GB-3002 "Hall E" 150 Seats
Classroom (maximimum 1)
Debrief Rooms
10 Seats
Debrief Rooms (maximum 8)
Simulation Rooms
Simulation Rooms (maximum 10)
LRCs
25 Seat Skills Labs
LRCs (maximum 2)
CS Exam Rooms
CS Exam Rooms (maximum 30)
Room Selection Notes / Specific Request
Note: As a courtesy to other programs and concurrent events please request only the rooms which are needed. If you are uncertain regarding your needs please provide as much detail as possible in the 'Additional Room Request Details' section.

Simulation Details
Select One:
Simulated Patient Name or Case Title
(If applicable)
Simulated Patient Name or Case Title
If you have completed a Simulation Scenario Development form please include the case ID here to ensure that the activity is linked with the case. Your case ID was included on your submission confirmation email.
Simulation Case ID
Simulation Case ID
Number of Simultaneous Cases
Number of Simultaneous Cases
Preferred Simulator Type
Select all that may apply
Simulation Notes
Upload Simulation Cases & Documents

Upload a File

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Task Trainer Details
Select One:
- Adult Airway Management Trainer
- Adult Airway Management Trainer
- Pediatric Airway Management Trainer
- Pediatric Airway Management Trainer
- Infant Airway Management Trainer
- Infant Airway Management Trainer
- Airway Demonstration Model
- Airway Demonstration Model
- Fiber Optic Airway Trainer
- Fiber Optic Airway Trainer
- Cricothyrotomy Trainer
- Cricothyrotomy Trainer
- Anesthetic Airway Trainer
- Anesthetic Airway Trainer
- "Seymour Butts" Wound Care Trnr
- "Seymour Butts" Wound Care Trnr
- "Chester Chest" Central Line Trnr
- "Chester Chest" Central Line Trnr
- "Surgical Sally" Wound Care Trnr
- "Surgical Sally" Wound Care Trnr
- Ostomy Care Trainer
- Ostomy Care Trainer
- Chest Tube Care Trainer
- Chest Tube Care Trainer
- Tracheostomy Care Model
- Tracheostomy Care Model
- Wound Care Buttox
- Wound Care Buttox
- Lumbar Puncture / Epidural Trainer
- Lumbar Puncture / Epidural Trainer
- IV Training Arm
- IV Training Arm
- Central Line Trnr, Upper Torso
- Central Line Trnr, Upper Torso
- Enema Trainer
- Enema Trainer
- Arterial Line Training Arm
- Arterial Line Training Arm
- Intradermal Injection Forearm
- Intradermal Injection Forearm
- Dysrhythmia Auscultation Trnr
- Dysrhythmia Auscultation Trnr
- Portable Heart/Lung Auscultation Trnr
- Portable Heart/Lung Auscultation Trnr
- Auscultation Torso
- Auscultation Torso
- Harvey Auscultation Simulator
- Harvey Auscultation Simulator
- Breast Exam Model
- Breast Exam Model
- Testicular Exam Model
- Testicular Exam Model
- Prostate Exam Model
- Prostate Exam Model
- "Breast Vest" Model
- "Breast Vest" Model
- Female Catherization Model
- Female Catherization Model
- Male Catherization Model
- Male Catherization Model
- Stages of Labor Model Set
- Stages of Labor Model Set
- PelvicSim Exam Simulator
- PelvicSim Exam Simulator
- Low Fidelity Adult
- Low Fidelity Adult
- Low Fidelity Child
- Low Fidelity Child
- Low Fidelity Toddler
- Low Fidelity Toddler
- Low Fidelity Infant
- Low Fidelity Infant
- Eye Exam Model
- Eye Exam Model
- Ear Exam Model
- Ear Exam Model
- Blood Pressure Training Arm
- Blood Pressure Training Arm
- Adult CPR Mannequin
- Adult CPR Mannequin
- Infant CPR Mannequin
- Infant CPR Mannequin
- Advanced Infant CPR Trainer
- Advanced Infant CPR Trainer
- Spinal-Pelvic Model
- Spinal-Pelvic Model
- Cross Sectional Anatomy Model
- Cross Sectional Anatomy Model
- 3D Anatomy Model
- 3D Anatomy Model
- Please include any further task trainer related notes here
- Please include any further task trainer related notes here

Medical Equipment Details
Select One:
- Single Channel IV Pump
- Single Channel IV Pump
- Three Channel IV Pump
- Three Channel IV Pump
- Kangaroo Feeding Pump
- Kangaroo Feeding Pump
- PCA Pump
- PCA Pump
- Arterial Line Setup/Faux Transducer
- Arterial Line Setup/Faux Transducer
- Pressure Infuser
- Pressure Infuser
- IV Pole
- IV Pole
- Hospital Floor Bed
- Hospital Floor Bed
- Hospital Transport Stretcher
- Hospital Transport Stretcher
- Pre-Hospital/EMS Stretcher
- Pre-Hospital/EMS Stretcher
- Obstetric Stretcher
- Obstetric Stretcher
- OR Table
- OR Table
- Dental Chair
- Dental Chair
- Hydraulic Patient Lift
- Hydraulic Patient Lift
- Overbed Table
- Overbed Table
- Examination Table
- Examination Table
- Opthalmoscope, Standard
- Opthalmoscope, Standard
- Otoscope, Standard
- Otoscope, Standard
- Panoptic Scope
- Panoptic Scope
- Bronchoscope, Fiber Optic, Handheld
  1 max
- Bronchoscope, Fiber Optic, Handheld
- Laryngoscope, Direct Laryngoscopy
- Laryngoscope, Direct Laryngoscopy
- Video Laryngocope
  3 max
- Video Laryngocope
- Thermometer, Oral
- Thermometer, Oral
- Blood Pressure Cuff, Standard
- Blood Pressure Cuff, Standard
- Blood Pressure Cuff, Pediatric
- Blood Pressure Cuff, Pediatric
- Blood Pressure Cuff, Large/Thigh
- Blood Pressure Cuff, Large/Thigh
- Stadiometer
  3 max
- Stadiometer
- Scale
- Scale
- Crash Cart
  3 max
- Crash Cart
- Anesthesia Cart
  4 max
- Anesthesia Cart
- Medication Cart
  2 max
- Medication Cart
- Small Supply Cart
  10 max
- Small Supply Cart
- Linen Cart
  1 max
- Linen Cart
- "ServeRx" Medication Dispensing System
  1 max
- "ServeRx" Medication Dispensing System
- "LifePak 12" Defibrilaltor
  2 max
- "LifePak 12" Defibrilaltor
- "Codemaster" Defibrillator
  1 max
- "Codemaster" Defibrillator
- AED Trainer
  2 max
- AED Trainer
- Mechanical Ventillator
  2 max
- Mechanical Ventillator
- "Aestiva" Anesthesia Machine
  3 max
- "Aestiva" Anesthesia Machine
- "Modulus" Anesthesia Machine
  3 max
- "Modulus" Anesthesia Machine
- Please include any further equipment related notes here
- Please include any further equipment related notes here

Consumable Supplies
Consumable supplies are supply items that are used and then discarded and include items such as gauze, syringes, procedural trays and single use mannequin inserts.
Funding

Other
Supply List
Please provide a detailed list of all supplies required below:

If requesting more than a small number of supplies we suggest that you utilize the link below and complete the ISC Supply Request form (excel) and upload below. Regardless, documentation must include number and description of each supply.

If only requesting a small number of supplies you may enter these supplies directly into the fields below under the 'Quick Supply Request (Optional)'.

All quantities are total per day. Please specify how they should be distributed either in your case documentation or in the notes.

All supply requests must be provided to the ISC not later than one month prior to your activity. Late requests may not be honored.
Click Here to Download the Supply Request Form

(Opens in a Google Document in a new tab, this page remains in background)

Please download, fill out, and upload completed document below
Upload Your Completed Supply Request Form Here

Upload

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- Supplies Required
- Paste your supply list here. Be sure to include quantities, descriptions and dates for all items.

Identify the Items You Have Edited
Briefly identify the edits which were made to the last submission, this assists ISC staff in processing your change request.
Agree and Submit Your Request
Review the documents below prior to submitting your request. These documents govern the use of the Augusta University Interdisciplinary Simulation Center and by submitting this request you agree to abide by the rules of the ISC and also agree to ensure compliance by your participants and faculty. All participants and faculty in your activity must sign a Code of Conduct Acknowledgement and AV Release prior to their activity. A copy of these documents will accompany your request confirmation.
ISC Code of Conduct
Agreement
ISC Fee Structure
Agreement
By signing I confirm that I have read the above required documentation and agree to abide by the code of conduct, the fee structure, and the regulations of the Interdisciplinary Simulation Center.
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Simulation Activity Request Form