Request for Clinical Learning
Please submit a separate request for each session, unless you are running the same simulation on multiple dates; if that’s the case, please note that in the date/time section. Thanks!
(Cell Phone Preferred)
Course # NRSG
Please provide a brief description of the simulation session.
Is this a revision of a request previously submitted.
Date(s) and Time(s) Requested:
Total # Students
Please tell us how many stations you are planning, how many students will be at each station at a time, and how many rooms you anticipate needing.
Has this simulation previously been done?
Please tell us what supplies and support you need provided. Please include, with numbers when possible:
• consumable supplies
• durable equipment
o level of functionality (what do you need the manikin to do?)
o moulage (this refers to how the manikin should appear in terms of age, gender, injuries, etc.)
• lab staff (e.g., simulator operator, reset stations)
If you are using your own equipment and supplies, please do not include those here.
Please provide any additional information we need to help you make this a successful learning experience for your students. This is also where you can let us know if you would like to have a brainstorming session and/or prefer to do a walkthrough prior to the scheduled experience.
Do Not Fill This Out