Simulation Design Form Requested Day of Activity Date Start Time End Time Case Title Insert Patient's Name, Age, Gender, or Patient Diagnosis Goals Target Audience Specify Student/Course Number/ and Year of Training as Appropriate Facilitator Name Upload the most recent simulation template? (Found on Simulation canvas site ) i.e. Skills Request Form, Simulation Design Template, SPCase TemplateOne file only.150 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp4, ogg, wav, svg, zip. Assessment Methodology Purpose of the assessment (Formative, Summative)What's being assessed? (Clinical knowledge, skills, professional behavior)How is it assessed? (Checklists, rubrics, direct observation, video review, debriefing discussion)Who assesses?Criteria for success? (Learning objectives tied to measurable outcomes) Curriculum Requirement - None - Yes No Not Sure Explanation of Curriculum Requirement Program and course numberWhy is it required/needed? (Meeting accreditation standard, program learning outcome)What gap does it fill? Assessment Tools (Faculty Rubric / SP Checklist)One file only.150 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp4, ogg, wav, svg, zip. Assessment Tools Development Summary Is it derived from a validated original tool? Which one?If not, explain the development process (who contributed and what objectives is it mapped to)?How, when, and by whom were faculty trained on the tool?If previously used, provide validity/reliability data. Anticipated Number of Rooms Needed Name and Roles of Faculty Involved Day of Event Will Simulated Participants be involved in the event? Equipment Required Feedback/Debriefing Plan (when, where, type: summative or formative) What faculty is leading and what is method of distributing information to students If applicable, when should videos/checklists be released? Proposed Planning Meeting Date (If new case) Proposed Planning Meeting Date: Date Proposed Planning Meeting Date: Time Complete Case Information Due Date (Required 6 weeks before event. Appointment will be sent as a reminder) Complete Case Information Due Date: Date Complete Case Information Due Date: Time Proposed Dry Run Date (If new case. Best within 2 weeks of the event) Proposed Dry Run Date: Date Proposed Dry Run Date: Time Additional Comments Leave this field blank
