Simulation Center Request Form:Emergency Medicine Department:SUNY Upstate Medical University

Simulation Center Request Form


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Simulation Center Request Form

Project Type:

Primary Objective:

Course Director/Project Leader:

*Phone Number:*
*Extension:*

Funding Source:

Billing Contact:

Project Name:

Description/General Goals:

Project Audience (Who you are training):

Project Details

Hours Per Session:

Sessions Per Week:

Number of Weeks:

Trainees Per Session:

Simulation Scenarios Per Session:

High-Fidelity Manequins Per Session:

  Adult 1
  Adult 2
  Child
  Infant

Skills Trainers:

  Airway
  Venus Access
  Other

DVD of Session: