August 1st 2024- July 31st 2025 HEC Request Form

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Please complete the survey below.

Thank you!

Welcome to the HEC Booking Request Form.
By selecting on the Agree button below, I confirm that I have read and understood all the HEC policies associated with the design, conduction, and evaluation of simulation activities in the HEC.

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Agree

Disagree

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I confirm this booking request is for a date taking place between August 1st 2024 and July 31st 2025

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Yes

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By selecting "Agree" I confirm that faculty or a teaching representative will be in attendance for the simulation activity being requested. I also understand that I may be asked to meet with HEC staff to discuss requirements of the Activity.

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Agree

Disagree

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Is this request for a didactic lecture only?
*no simulation, skills, or Standardized Patients

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Yes

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Please note, the form is only for scheduling simulation activities in HEC skills and simulation areas. The large learning studios and group study rooms located on the south side of the HEC can be reserved via the Classroom Services scheduling system. The link to Classroom Services can be found below.

https://www.utmb.edu/ar/academic-resources/classroom-services

Please select the type of simulation activity you will be conducting in the HEC.

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Human [Standardized Patients]

Non-Human [Skills, task trainers, simulators/mannequins, anatomage]

Virtual Reality

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Is this VR activity an in-person (at HEC) or remote (e.g. at home) activity?

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In-person

Off campus (computer-based)

Both

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Type of VR activity:

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Virtual Human

360

Mixed (both Virtual Human and 360)

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Please select if this is a new or established activity.

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New

Established

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Please select School/Department Affiliation.

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School of Medicine

School of Nursing

School of Health Professions

School of Public and Population Health

Graduate School of Biomedical Sciences

UTMB Residency or Fellowship

Interprofessional Education Activity

Student Organization/Student Interest Group

Other

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Please list "other" School affiliation

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Please list UTMB Residency or Fellowship Program

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Please provide name of Student Organization/Student Interest Group

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Please provide the course name and number (if applicable). If the request is not associated with a course, please provide the department name and level of learner.

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Please provide the preferred date(s) for conducting this activity.

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Where possible, please provide up to three alternate dates for this activity.

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Please provide the required scheduled times (i.e. 09:00-14:00) for this activity.

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If this exact activity is to be repeated, please provide the further dates and times required. Please put N/A if it is not repeated in the same semester.

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Please provide the name of the course director and any affiliated instructor(s).

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Please provide contact email address and telephone number for course director.

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Please select the spaces that are required for this booking.

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HEC Skills & Simulation Labs

Mechanic Labs (SHP/SON 1.600/1.706)

Market Streets Labs (1.200/1.202/1.214/1.216)

Graves Labs 3.310

Please select the HEC room(s) on Floor 1 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.

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None

Ambulance Bay (1.904)

Please select the HEC room(s) on Floor 2 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.

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None

Classroom, Large Debrief (2.300)

Wet Lab (2.400)

Skills Lab A - Exam Tables (2.408)

Skills Lab B - Hospital Beds (2.418)

Skills Lab C - Stretcher Beds (2.910)

VR/Anatomage Suite (2.200)

Please select the HEC Virtual Reality Suite for this activity.

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Virtual Reality Suite

Please select the HEC room(s) on Floor 3 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.

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None

Large Debrief 3A (3.106)

Large Debrief 3B (3.914)

Small Debrief 1 (3.620)

Small Debrief 2 (3.622)

Adult 301 (3.600)

Adult 302 (3.602)

Adult 303 (3.606)

Adult 304 (3.610)

Adult 314 (3.616)

Adult 315 (3.612)

Adult 316 (3.608)

Adult 317 (3.604)

Neo/Child 305 (3.628)

Neo/Child 306 (3.632)

Neo/Child 307 (3.636)

Neo/Child 308 (3.640)

Neo/Maternal 310 (3.638)

Neo/Maternal 311 (3.634)

Neo/Maternal 312 (3.630)

Neo/Maternal 313 (3.624)

Sim OB Suite (3.912)

Sim Home (3.104)

Please select the HEC room(s) on Floor 4 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.

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None

Medium Debrief 4A (4.100)

Large Debrief 4B (4.140)

Large Debrief 4C (4.142)

Exam Room 1 (4.300D)

Exam Room 2 (4.300C)

Exam Room 3 (4.300B)

Exam Room 4 (4.300A)

Exam Room 5 (4.300H)

Exam Room 6 (4.300G)

Exam Room 7 (4.300F)

Exam Room 8 (4.300E)

Exam Room 9 (4.700D)

Exam Room 10 (4.700C)

Exam Room 11 (4.700B)

Exam Room 12 (4.700A)

Hospital Room 13 (4.700H)

Hospital Room 14 (4.700G)

Hospital Room 15 (4.700F)

Hospital Room 16 (4.700E)

SP Training 1 (4.420)

SP Training 2 (4.418)

SP Training 3 (4.414)

Please select the HEC room(s) on Floor 5 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.

* must provide value

None

Debrief Room 5A (5.402)

Debrief Room 5B (5.434)

ICU Room 501 (5.406)

ICU Room 502 (5.408)

ICU Room 503 (5.412)

ICU Room 504 (5.414)

ICU Room 505 (5.418)

ICU Room 506 (5.422)

ICU Room 507 (5.426)

ICU Room 508 (5.430)

ICU Room 509 (5.420)

ICU Room 510 (5.410)

OR Suite 1 (5.438)

OR/PACU Suite 2 (5.442)

Please select the Mechanic Street Labs (SHP/SON) required for this activity.

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None

1.600

1.706

Please select the Graves Labs required for this activity.

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None

3.310 Large Exam Room #1

3.310 Large Exam Room #2

3.310 Large Exam Room #3

3.310 Exam Room #4

3.310 Exam Room #5

3.310 Exam Room #6

3.310 Exam Room #7

3.310 Exam Room #8

3.310 Exam Room #9

Please select the Market Street Labs required for this activity.

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None

1.200

1.202

1.214

1.216

Please select the type of activity being conducted.

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Learning activity

Formative assessment

Summative assessment

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Is this activity required for graduation or advancement in a program?

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Yes

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Does this activity involve any non-UTMB participants?

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Yes

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Please provide a brief description of the non-UTMB participants and number of learners.

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Please provide the approximate number of learners involved with this activity.

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Is this a group activity? If so, how many participants per group?

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Please indicate the type of simulators/mannequins required for this activity.

Please visit HEC's "Meet the Patient Simulators" to learn more.

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No Simulators/Mannequins Required

Anatomage table(s)

CAE-HPS(s)

CAE-Apollo(s)

CAE-Juno(s)

CAE-Vimedix

Laerdal-SimMan-3G(s)

Laerdal-Adult Kelly(s)

Gaumard-Noelle(s)

Gaumard-Victoria(s)

Laerdal-SimBaby(s)

Laerdal-Sim NewB(s) -

Baby Doll(s)

SIM Characters Paul(s)

Gaumard-Tory(s)

Gaumard Newborn-Hal(s)

Gaumard Pediatric Hal(s)

Laerdal Kelly Kid(s)

Laerdal Sim Junior(s)

Other Simulator Required

Other Simulator/Mannequin Required

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Please indicate the quantity of Anatomage table(s) required for this activity.
HEC quantity - 6

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Will you require assistance with operating the anatomage tables from HEC simulations staffing as part of the activity?

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Yes

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Will you require assistance from HEC simulation staff with designing course materials for the anatomage tables?

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Yes

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Please indicate the quantity of CAE-Vimedix(s) required for this activity.
HEC quantity - 2

* must provide value

Please indicate the quantity of CAE-HPS(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of CAE-Apollo(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of CAE-Juno(s) required for this activity.
HEC quantity - 10

* must provide value

Please indicate the quantity of Laerdal-SimMan-3G(s) required for this activity.
HEC quantity - 18

* must provide value

Please indicate the quantity of Laerdal-Adult Kelly(s) required for this activity.
HEC quantity - 10

* must provide value

Please indicate the quantity of Gaumard-Noelle(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of Gaumard Victoria(s) required for this activity.
HEC quantity - 2

* must provide value

Please indicate the quantity of Laerdal-SimBaby(s) required for this activity.
HEC quantity - 7

* must provide value

Please indicate the quantity of Laerdal-Sim NewB(s) required for this activity.
HEC quantity - 6

* must provide value

Please indicate the quantity of Baby Doll(s) required for this activity.
HEC quantity - 32

* must provide value

Please indicate the quantity of SIM Characters Paul(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of Gaumard-Tory(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of Gaumard Newborn-Hal(s) required for this activity.
HEC quantity - 2

* must provide value

Please indicate the quantity of Gaumard Pediatric Hal(s) required for this activity.
HEC quantity - 1

* must provide value

Please indicate the quantity of Laerdal Kelly Kid(s) required for this activity.
HEC quantity - 9

* must provide value

Please indicate the quantity of Laerdal Sim Junior(s) required for this activity.
HEC quantity - 2

* must provide value

Please select the equipment and/or task trainers required for your activity:

* must provide value

No equipment or task trainers required

CU Ventilator(s)

BiPaP V60(s)

Airvo(s)

RespiPatient + ASL(s)

Anesthesia Machine(s)

Adult Code Cart(s)

Pediatric Code Cart(s)

Defibrillator(s)

Central line dressing change trainer(s) - Chester Chest

Central line insertion trainer(s) - IJ/Subclavian

Central line insertion trainer(s) - Femoral

Knee Injection Trainer(s)

Shoulder Injection Trainer(s)

Infusion Pump(s)

Ultrasound(s)

ButterflyIQ ultrasound probe(s)

Portable Doppler(s)

IV Arm(s)

IV Push Pad(s)

Blood Pressure Arm(s)

Blood Pressure Cuff(s)

Injection Pad(s)

Male Pelvic Model(s)

Female Pelvic Model(s)

Noelle birthing task trainer(s)

OB Susie birthing task trainer(s)

Breast Model(s)

SAM(s) II

Pyxis

Other Equipment(s)

Please select the quantity of central line insertion trainer(s) -IJ/subclavian required for your activity:
HEC quantity - 1

* must provide value

Please select the quantity of central line insertion trainer(s) - Femoral required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of knee injection trainer(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of shoulder injection trainer(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of Noelle birthing task trainer(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of OB Susie birthing task trainer(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of CU Ventilator(s) required for your activity:
HEC quantity - 12

* must provide value

Please select the quantity of BiPaP V60(s) required for your activity:
HEC quantity - 1

* must provide value

Please select the quantity of Airvo(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of RespiPatient(s) with ASL required for your activity:
HEC quantity - 1

* must provide value

Please select the quantity of Anesthesia Machine(s) required for your activity:
HEC quantity - 3

* must provide value

Please select the quantity of Adult Code Cart(s) required for your activity:
HEC quantity - 8

* must provide value

Please select the quantity of Pediatric Code Cart(s) required for your activity:
HEC quantity - 3

* must provide value

Please select the quantity of Central line dressing change - Chester Chest(s) required for your activity:
HEC quantity - 22

* must provide value

Please select the quantity of Infusion Pump(s) required for your activity:
HEC quantity - 48

* must provide value

Please select the quantity of Defibrillator(s) required for your activity:
HEC quantity - 4

* must provide value

Please select the quantity of Ultrasound(s) required for your activity:
HEC quantity - 4

* must provide value

Please select the quantity of ButterflyIQ ultrasound probe(s) required for your activity:
HEC quantity - 2

* must provide value

Please select the quantity of Portable Doppler(s) required for your activity:
HEC quantity - 4

* must provide value

Please select the quantity of IV Arm(s) required for your activity:
HEC quantity - 37

* must provide value

Please select the quantity of IV Push Pad(s) required for your activity:
HEC quantity - 22

* must provide value

Please select the quantity of Blood Pressure Arm(s) required for your activity:
HEC quantity - 6

* must provide value

Please select the quantity of Blood Pressure Cuff(s) required for your activity:
HEC quantity - 21

* must provide value

Please select the quantity of Injection Pad(s)required for your activity:
HEC quantity - 82

* must provide value

Please select the quantity of Male Pelvic Model(s) required for your activity:
HEC quantity - 4

* must provide value

Please select the quantity of Female Pelvic Model(s) required for your activity:
HEC quantity - 10

* must provide value

Please select the quantity of Breast Model(s) required for your activity:
HEC quantity - 8

* must provide value

Please select the quantity of SAM(s) II required for your activity:
HEC quantity - 10

* must provide value

Please select the quantity of Other Equipment(s) required for your activity:

* must provide value

Please provide a list including quantities of disposable/non-disposable supplies required for this activity (i.e. 20 pairs of surgical gloves, 5 scrub brushes, 10 disposable gowns, etc.). Alternatively, you may provide a completed template in the designated section at the end of this form.

* must provide value

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Please outline room set-up requirements for this activity.

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Please list a minimum of three course objectives.

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Does a written case/scenario already exist for this activity? If yes, please provide the case/scenario name.

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Does an SP checklist already exist or does it need to be created?

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Already exists

Drafted

Needs to be created

Not Required

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Please provide the approximate number of SPs required for the activity.

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Does a door sign already exist for this activity or does it need to be created?

* must provide value

Already exists

Drafted

Needs to be created

Not required

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Please indicate if access to review recordings is required. Please select all that apply.

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Course Director

Designated Faculty

Participants

Access Not Required

Will the monitoring room be required for faculty observation and/or scoring?

* must provide value

Yes

To be determined

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Will a Post-encounter station be required as part of this activity?

* must provide value

Yes

To be determined

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Please provide approximate length of time per SP encounter (i.e. 15 min, 30 min, etc).

* must provide value

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Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).

Upload file

Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).

Upload file

Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).

Upload file

Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).

Upload file

Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).

Upload file

Please upload any/all related materials.

Upload file