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 (Required)
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 (Optional)
Secondary Contact Name

First NameLast Name
Secondary Contact Phone Number

Area CodePhone Number
Secondary Contact Email
example@augusta.edu

Budget Administrator Contact (If using supplies, or fee for service)
Budget Contact Name

First NameLast Name
Budget Contact Phone Number

Area CodePhone Number
Budget Contact Email
example@augusta.edu

collapse stopper
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:*

Room(s) in the Simulation Center (for simulation, skills, workshops, OSCEs, etc.)High or Medium Fidelity Simulation (computerized mannequins)Task Trainers, Anatomical Models, Low Fidelity Mannequins, or Other Training AidsMedical Equipment (including furniture, carts, pumps, etc.)Consumable Supplies (supply items to be used and then discarded)Telehealth Equipment (requires special facilitator training before session)Help connecting to a WebEx session which you or your program will setup
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.

ISC Facility Map

collapse stopper

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

Cancelof

Task Trainer Details
Select One:*

Airway Management
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

Nursing Care
"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

Procedural Training
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

Auscultation Training
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

Reproductive Health
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 Mannequins
Low Fidelity Adult
Low Fidelity Adult
Low Fidelity Child
Low Fidelity Child
Low Fidelity Toddler
Low Fidelity Toddler
Low Fidelity Infant
Low Fidelity Infant

Examination Models
Eye Exam Model
Eye Exam Model
Ear Exam Model
Ear Exam Model
Blood Pressure Training Arm
Blood Pressure Training Arm

CPR Mannequins
Adult CPR Mannequin
Adult CPR Mannequin
Infant CPR Mannequin
Infant CPR Mannequin
Advanced Infant CPR Trainer
Advanced Infant CPR Trainer

Anatomical Models
Spinal-Pelvic Model
Spinal-Pelvic Model
Cross Sectional Anatomy Model
Cross Sectional Anatomy Model
3D Anatomy Model
3D Anatomy Model

Other / Comments
Please include any further task trainer related notes here
Please include any further task trainer related notes here

stop collapse

Medical Equipment Details
Select One:*

Pumps and Infusion
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

Beds and Clinical Furniture
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

Examination/Office Tools
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

Carts
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

Critical Care and Anesthesia
"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

Other / Comments
Please include any further equipment related notes here
Please include any further equipment related notes here

stop collapse

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*

I need a quote and will reimburse the ISC for supplies usedI will bring my own suppliesOther
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

Cancelof

Quick Supply Request (optional)
Supplies Required

Stop Collapse

Free Text Supply List (optional)
Paste your supply list here. Be sure to include quantities, descriptions and dates for all items.

stop collapse

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*

I have read and understand the "Authorization, Assignment, and Release of Liability Agreement" above and I will ensure compliance.
ISC Fee Structure
Agreement*

I have read and understand the fee structure and how it applies to my activity.
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.*
Should be Empty:

Simulation Activity Request Form