Operating Hours M-F 8-5

CENTER FOR VIRTUAL CARE

CVC Phone – 916-734-4708

Event Request Form

This form is required to request all events in the Center for Virtual Care. For all educational events, a courseroster of learners is also required for each session. In addition, if your event includes a high fidelity scenario, complete the scenario stem section for each station. Please submit all completed forms to .

Date of Submission / Requested By
Contact Information / Event Coordinator / Faculty/Instructor of Record
Name
Phone
Email
Official Event Title
New Event? Yes No / School/Department / Cost Center
Date(s) and Time(s) Requested:
Note: This request will be reviewedconfirmation email will be delivered to the Coordinator and Faculty/Instructor of Record.
Equipment Needs for Course: Low Fidelity/Task trainer High Fidelity Manikin
Setting for Event:Adult Pediatric Neonate Acute Care Clinic OR
Other:
If your event does not involve education of learners, please provide the reason for your request (tour, filming, research, etc.):
On-site Coordinator(s) / Note: An on-site coordinator is required for courses with > 15 learners or > 2 stations.
EDUCATION BASED TRAINING
Please complete the following sections for all educational activities.
Target AudienceIn addition to the following learner summary, please email a roster prior to your session.
Anticipated Number of Learners: ( Internal and/or External)
Learner Level (e.g. Medical Student, Resident, Nurse, etc.):
Simulation spaces in the CVC have a maximum capacity of 15 learners (some less). For large groups, plan on multiple stations/rotations.
Course Agenda
Station / Start Time / End Time / Size of Group / Station Topic(e.g. suturing, code simulation, etc.) / Training Method (e.g. task station, patient scenario, etc.) / Faculty
1
2
3
4
5
6
Note: Lecture space can be reserved at
Brief Course Outline
Learning Objectives
1.
2.
3.
4.
5.
How will learners receive feedback? (select all that apply)
immediate debrief / follow-up discussion / written evaluation
How will learners be assessed? (select all that apply)
pre/post tests / individual rating / faculty observation
CVC Task Training Equipment Requested (Requester is responsible for consumable items)
Please list all training supplies/equipment you will be bringing from your area:
Audio Visual Support
A/V Presentation (Note: Not Mac Compatible) / Panopto recording B-Line recording
SCENARIO BASED TRAINING
Please complete the following sections if your educational activity includes high-fidelity patient simulation.
Simulated Patient(s) Request
Adult # / Peds # / Neonate # / Birthing Trainer
Other:
Scenario Stem: (i.e.: Stem #1:Clinic setting, 64 y/o male,complaint of abd pain for 8 hours. PE: pale, cool, diaphoretic, tachypnea, edema to lower ext.)
Stem #1:
Stem #2:
Stem #3:
Stem #4:
Additional Resources (i.e.: require an ECG machine, defibrillator, US machine, etc.)

2018.1.8