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Clinical Simulation Setup Form


This form should be completed after booking your simulation session. Fill in the form as completely as possible for each scenario you wish to run. If you wish to run multiple scenarios on the same day, a separate patient scenario setup form is required for each scenario. This is to ensure the lab is properly set up, manikins are configured properly and the proper schedule is set. The simulation staff will schedule a meeting with you to discuss your setup. This form should be completed and submitted prior to the meeting.

Faculty Name  
Course Number  
Date(s)   
 
   
   
Scenario Information
 
 
   
Patient Information (Please submit one completed form for each patient scenario)
 
 
    

 
 
 

Initial Vitals at Start of Scenario

 
Drugs to be Administered: (Please do not leave blank, enter None if no drugs are to be used)
Change in vitals after drug (enter NA if none)
Change in vitals after drug (enter NA if none)
Change in vitals after drug (enter NA if none)
   
   
 
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