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
I confirm this booking request is for a date taking place between August 1st 2023 and July 31st 2024
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Yes
No
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
Is this request for a didactic lecture only?
*no simulation, skills, or Standardized Patients
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Yes
No
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]
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
Other
Please list "other" School affiliation
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Please list UTMB Residency or Fellowship Program.
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Has this activity been approved by any of the following?
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Please select all that apply.
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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(MM/DD/YY)
Where possible, please provide up to three alternate dates for this activity.
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(MM/DD/YY)
Please provide the required scheduled times (i.e. 09:00-14:00) for this activity.
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Please use 24 hour clock (09:00-13:00; 14:00-17:00)
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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For example 2/12 09:00-12:00 and 3/3 13:00-16:00
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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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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For a complete set of HEC floor plans please copy and paste the following address into your browser: https://www.utmb.edu/hec/floor-plans
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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For a complete set of HEC floor plans please copy and paste the following address into your browser: https://www.utmb.edu/hec/floor-plans
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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For a complete set of HEC floor plans please copy and paste the following address into your browser: https://www.utmb.edu/hec/floor-plans
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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For a complete set of HEC floor plans please copy and paste the following address into your browser: https://www.utmb.edu/hec/floor-plans
Please select the HEC room(s) on Floor 5 required for this activity. Please include pre-brief/debrief and simulation rooms for the activity.
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For a complete set of HEC floor plans please copy and paste the following address into your browser: https://www.utmb.edu/hec/floor-plans
Please select the Mechanic Street Labs (SHP/SON) required for this activity.
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Please select the Graves Labs required for this activity.
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Please select the Market Street Labs required for this activity.
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Please select the type of activity being conducted.
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Learning activity
Practice examination
Low-stake examination
High-stake examination
Is this activity required for graduation or advancement in a program?
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Yes
No
Please select if this is a new or established activity.
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New
Established
Does this activity involve any non-UTMB participants?
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Yes
No
Please provide a brief description of the non-UTMB participants.
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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.
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Other Simulator/Mannequin Required
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Please indicate the quantity of Anatomage table(s) required for this activity.
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Please indicate the quantity of CAE-Vimedix(s) required for this activity.
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Please indicate the quantity of CAE-HPS(s) required for this activity.
Please indicate the quantity of CAE-Apollo(s) required for this activity.
Please indicate the quantity of CAE-Juno(s) required for this activity.
Please indicate the quantity of Laerdal-SimMan-3G(s) required for this activity.
Please indicate the quantity of Laerdal-Adult Kelly(s) required for this activity.
Please indicate the quantity of Gaumard-Noelle(s) required for this activity.
Please indicate the quantity of Laerdal Sim Mom(s) required for this activity.
Please indicate the quantity of Laerdal-SimBaby(s) required for this activity.
Please indicate the quantity of Laerdal-Sim NewB(s) required for this activity.
Please indicate the quantity of Baby Doll(s) required for this activity.
Please indicate the quantity of SIM Characters Paul(s) required for this activity.
Please indicate the quantity of Gaumard-Tory(s) required for this activity.
Please indicate the quantity of Gaumard Newborn-Hal(s) required for this activity.
Please indicate the quantity of Gaumard Pediatric Hal(s) required for this activity.
Please indicate the quantity of Laerdal Kelly Kid(s) required for this activity.
Please indicate the quantity of Laerdal Sim Junior(s) required for this activity.
Please select the equipment and/or task trainers required for your activity:
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Please select the quantity of central line insertion trainer(s) -IJ/subclavian required for your activity:
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Please select the quantity of central line insertion trainer(s) - Femoral required for your activity:
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Please select the quantity of Noelle birthing task trainer(s) required for your activity:
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Please select the quantity of OB Susie birthing task trainer(s) required for your activity:
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Please select the quantity of CU Ventilator(s) required for your activity:
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Please select the quantity of Anesthesia Machine(s) required for your activity:
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Please select the quantity of Adult Code Cart(s) required for your activity:
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Please select the quantity of Pediatric Code Cart(s) required for your activity:
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Please select the quantity of Chester Chest(s) required for your activity:
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Please select the quantity of Infusion Pump(s) required for your activity:
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Please select the quantity of Defibrillator(s) required for your activity:
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Please select the quantity of Ultrasound(s) required for your activity:
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Please select the quantity of Portable Doppler(s) required for your activity:
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Please select the quantity of IV Arm(s) required for your activity:
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Please select the quantity of IV Push Pad(s) required for your activity:
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Please select the quantity of Blood Pressure Arm(s) required for your activity:
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Please select the quantity of Blood Pressure Cuff(s) required for your activity:
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Please select the quantity of Injection Pad(s)required for your activity:
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Please select the quantity of Male Pelvic Model(s) required for your activity:
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Please select the quantity of Female Pelvic Model(s) required for your activity:
Please select the quantity of Breast Model(s) required for your activity:
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Please select the quantity of SAM(s) II required for your activity:
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Please select the quantity of Other Equipment(s) required for your activity:
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If utilizing patient simulators/mannequins, will you require assistance with operating the simulators/mannequins from HEC staffing as a part of the activity?
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The course has and will provide expertise with operation of simulators
The course has and will provide expertise with operation and we will also require assistance with operation of simulators from the HEC
The course will require assistance with operation of simulators from the HEC
No simulators required for the activity
Additional cost may be incurred if requesting HEC PBL (paid by letter) staff to provide assistance with operation of simulators. This will be confirmed if the request is approved.
How many PBL's do you require to assist you with this activity?
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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.
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If utilizing a template, please respond "uploaded below" to this question.
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
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?
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Already exists
Drafted
Needs to be created
Not required
If this document already exists or is in draft format, please upload in the section at the end of the form.
If the activity is to be recorded, who should be given access to review? Please select all that apply.
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Please note the HEC will record on all sessions for quality assurance processes (apart from MUTA/GTA)
Will the monitoring room be required for faculty observation and/or scoring?
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Yes
No
To be determined
Will this activity require Proctoring services from the HEC?
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Yes
No
To be determined
Additional cost may be incurred if requesting HEC staff for proctoring services. This will be confirmed if the request is approved.
Will a Post-encounter station be required as part of this activity?
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Yes
No
To be determined
Please provide approximate length of time per SP encounter (i.e. 15 min, 30 min, etc).
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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.).
Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).
Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).
Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).
Please upload any/all related course materials (i.e. scenario, lab values, set-up requirements, patient notes, supply list/template, etc.).
Please upload any/all related course materials (i.e. case scenario, time keeper script, door sign, IP/SP checklist, scoring rubric, supply list/template, etc.).
Please upload any/all related course materials (i.e. case scenario, time keeper script, door sign, IP/SP checklist, scoring rubric, supply list/template, etc.).
Please upload any/all related course materials (i.e. case scenario, time keeper script, door sign, IP/SP checklist, scoring rubric, supply list/template, etc.).
Please upload any/all related course materials (i.e. case scenario, time keeper script, door sign, IP/SP checklist, scoring rubric, supply list/template, etc.).
Please upload any/all related course materials (i.e. case scenario, time keeper script, door sign, IP/SP checklist, scoring rubric, supply list/template, etc.).
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