Build Your Simulation Activity

If you are interested in building a simulation activity, use the form below to provide us with the necessary information to get started planning your activity. Please fill in as much information as you can.

Spam Protection (leave blank)
Developer Contact Information
Name *
Phone Number
Email *
Affiliation
Prior Simulation Experience
Prior Education Experience
Other Developers and their Contact Info (if any)
Activity Information
Anticipated Date of Activity
Activity Title
General Statement of Activity Educational Objective(s) / Goal(s)
Structural Level of Learning Activity Course
Module in an Existing Course
Demonstration
Instructors Information
Anticipated # of Instructors
Instructor/Student Ratio
Names & Contact Info of other instructors if known
Participants Information
Anticipated number and type(s) of Participants
More Activity Information
Anticipated Type of Learning Activity (you may select more than one) I don't know
Individual Competency Training
Problem-based Learning Activity
Team Training
Skill Training
Classroom Demonstration
Other (please specify)
Desired Educational Outcome Measurement None
I don't know
Participant Evaluation
Cognitive Exam
Skill-based Exam
High fidelity simulator-based Evaluation
of Knowledge, Skills, & Judgment, Debriefing
Other (please specify)
Known Limitations on Activity Development None
Time
Financial Resources
Number of Available Instructors
Other (please specify)
What resources do you feel you will need for this activity?
Classroom Set Up
A/V Equipment
Hospital Supplies
Simulators
Simulation Rooms
Additional Information
What materials do you currently have available?
How much anticipated set up/take down time do you need?
Will you be providing meals/refreshments?
Meeting date/time with Dr. Brown and/or Simulation Specialist
Palmetto Health University of South Carolina

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