Qualtrics Survey | Qualtrics Experience Management

Name Of Requestor:

Phone Number:

Email:

Semester Simulation Requested:

Spring 2025 (Jan-May)
Summer 2025 (May-July)

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:

Mental Health Case Requested:

Depression
Schizophrenia
Substance Abuse Disorder- Alcohol Detox
Substance Abuse Disorder- Benzodiazepine Withdrawal
Combination of above:

What course objective does this simulation address? (Copy and paste objective(s) below)

What program objective does this simulation address? (Copy and paste objective(s) below)

Audio Visual Needs:

Live Viewing
Recording & Playback Capability
None Needed

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

Yes
No
Maybe

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.