Qualtrics Survey | Qualtrics Experience Management

Name Of Requestor:

Phone Number:

Email:

Date(s) Requested:

Simulation Center Site Preference:

Cook Hall, RU Main Campus
Roanoke Higher Education Center

Learner Group Description:

Department: (A fee may apply to external users outside of the School of Nursing)
Level:
Course Number:

Number of Learners:

For simulation service requests, please complete the following information and details.

Type of Simulation Service Requested:

Skills/Procedural Training
Space Needed
Preprogrammed Nursing scenarios. Name of scenario(s) requested:
CSC Standardized Patients Needed. Explain case:
Combination of above:

Goals/Learning Objectives:

Audio Visual Needs:

Live Viewing
Recording & Playback Capability
None Needed

Will you be sending faculty to conduct the simulation and debriefing?

Yes
No
Maybe

Do you have your requested simulation activity already designed and programmed(if not using a CSC preprogrammed simulation)?

Yes
No
Requesting design and/or programming assistance from CSC faculty

Please indicate several dates and times you are available to meet with the Director, Simulation Faculty, and/or Program Manager to discuss details of your request. Include ability to meet in person at the center or virtually.