Skills Labs and Acute Care Areas Simulation Equipment & Supply Request Form

This form is for College of Nursing related simulation requests only.

Degree Program*

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Course Number & Name*

Requestor's Name*

Requestor's Email*

Cell Phone Number

Number of Students Participating in Activity*

Semester/Term of Activity*

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Date of Activity*

Start Time*

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End Time*

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Is this a recurring activity?*

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Dates/times for recurring activities

Instructors Present*

Type of Activity*

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Room Preference(s)*

Please select all options you would like to request for your activity.

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Description of "Other"

Number of Virtual Simulation Licenses

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Skill Being Simulated?

Describe the skill(s) that are being simulated during this session (i.e., intubation, mobility, perfusion, physical assessment, wound care, etc.).

Technical Support Requirements*

Self-support: The user/requestor will prep, turn on, run, and shut down the equipment needed for the session. No need for additional technical assistance/support is required during the session. Please note: If training is required, please schedule at least 1 week ahead of the session with the IHSC Simulation Staff by emailing: hsc-con-simulation@salud.unm.edu. Initial set up and self-run sessions: Simulation specialists will prep and turn on the simulator. No additional technical support is required during the session. User/requestor is responsible for shutting down the equipment. Full technical support: Simulation specialist will prep and turn on simulator. Technical support will be available during the session to assist as necessary. Simulation specialist will shut down equipment once session is complete.

Self-Support

Initial set up and self-run

Full technical support

Staging of Simulation Space

Please specify set-up needs for each room and bed needed for the activity and whether or not different staging will be needed for different rooms. Please provide the room number and bed number for each set up. A map including room numbers for the Interprofessional Health Sciences Center can be found online at: https://hslic.unm.edu/ihsc/docs/IHSC%20Simplified%20Map.pdf.

Staging of Simulation Space

Simulation Manikins

Please provide details on which (if any) simulation manikins and how many of each will be needed for this activity.

Sim 3G Quantity

SimMom Quantity

SimJr Quantity

Sim Newborn Quantity

Suzie Quantity

Mid-Fidelity Manikin Quantity

Low-Fidelity Manikin Quantity

Other Description and Quantity

Patient Information

Please provide the following information for each patient/simulators for which ID bands are required: Name, Date of Birth, Medical Record Number, and Allergies.

Patient 1 Information

Patient 2 Information

Patient 3 Information

Patient 4 Information

Additional Patient(s) Information

Medications Needed

Please provide the following information regarding medications needed for this simulation activity. Up to 10 medications may be requested in this section. Should additional medications be needed for this activity, please attach a document at the end of this request with detailed information.

Medication 1 Generic Name

Medication 1 Label Dosage

Medication 1 Quantity

Medication 1 Delivery Method

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Medication 1 Description of "Other"

Medication 2 Generic Name

Medication 2 Label Dosage

Mediication 2 Quantity

Medication 2 Delivery Method

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Medication 2 Description of "Other"

Medication 3 Generic Name

Medication 3 Label Dosage

Medication 3 Quantity

Medication 3 Delivery Method

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Medication 3 Description of "Other"

Medication 4 Generic Name

Medication 4 Label Dosage

Medication 4 Quantity

Medication 4 Delivery Method

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Medication 4 Description of "Other"

Medication 5 Generic Name

Medication 5 Dosage Level

Medication 5 Quantity

Medication 5 Delivery Method

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Medication 5 Description of "Other"

Supplies and Equipment Needed

Please provide detailed information regarding the types and quantities of supplies needed for this activity.

Supplies/Equipment Requested*

Additional Information

Please provide any additional information that will assist the IHSC Simulation Team with preparing for your activity.

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