Setting/Environment
☐ Emergency Room☐ ICU
☐ Medical-Surgical Unit☐ OR / PACU
☐ Pediatric Unit☐ Rehabilitation Unit
☐ Maternity Unit☐ Home
☐ Behavioral Health Unit☐ Outpatient Clinic
☐ Other:
Equipment/Supplies (choose all that apply to this simulation)
Simulated Patient/Manikin/s Needed:
Recommended Mode for Simulator:
(i.e. manual, programmed, etc.)
Other Props & Moulage:
Equipment Attached to Manikin/Simulated Patient: ☐ ID band ☐ IV tubing with primary line fluids running at __mL/hr ☐ Secondary IV line running at __mL/hr ☐ IVPB with ______ running at mL/hr ☐ IV pump ☐ PCA pump ☐ Foley catheter with ______ mL output ☐ 02 ☐ Monitor attached ☐ Other: Other Essential Equipment: Equipment Available in Room: ☐ Bedpan/urinal ☐ 02 delivery device (type) ☐ Foley kit ☐ Straight catheter kit ☐ Incentive spirometer ☐ Fluids ☐ IV start kit ☐ IV tubing ☐ IVPB tubing ☐ IV pump ☐ Feeding pump ☐ Crash cart with airway devices and emergency medications ☐ Defibrillator/pacer ☐ Suction ☐ Other:
Medications and Fluids: ☐ Oral Meds: ☐ IV Fluids: ☐ IVPB: ☐ IV Push: ☐ IM or SC: