Loyola University Chicago Health Sciences Campus
Center for Simulation Education Activity Request Form

* required fields

*Activity Title:

*Activity Director:

*Contact Person:

*Phone Number:

*E-Mail Address:

*Please re-enter your E-mail Address to confirm:

*Department:

*Learners:

*Needs Assessment
How did you establish the need for this Activity? Describe current practice as well as best practice. Please provide any references.

*Measurable Instructional Objectives
List 3-4 measurable instructional objectives. At the end of the Activity learner will be able to:

*Simulation Modalities Utilized

 Standardized Patients
Task Trainer Models
High-fidelity mannequin (adult, pediatric)
Virtual Reality Trainer
Surgical Skills Workshop (cadaver or specimen)
Uncertain

*Number of Learners

*Level of Learners

*Number of Instructors

*Session Duration

List Assessment Instruments (if applicable)

*Who are the instructors/raters?

 Faculty
Residents
Staff
Students
Other
Center for Simulation Education personnel

*Instructor/Rater training provided by

 Department
Center for Simulation Education