Qualtrics Survey | Qualtrics Experience Management

Name Of Requestor:

Phone Number:

Email:

Simulation Center Site Preference:

Cook Hall, RU Main Campus
Roanoke Higher Education Center

Number of Learners:

Semester Requested

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

Please list requested dates or week # into the semester when this simulation will best meet curricular needs.

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

Each pre-programmed scenario is 1.5 clock hours. Morning or Afternoon blocks include 2 scenarios. Please choose which one(s) you are requesting:

Med-Surg Complex/Critical Care Adult Scenarios

Acute Coronary Syndrome

Heart Failure

SCI with paralysis 18 y.o.

Acute Ischemic Stroke

Post-op Appendectomy

Possible: Stab wound with hemothorax

COPD

Pediatric Scenarios

Post-op Appendectomy, 6 y.o.

Diabetes Type I, 16 y.o.

Possible: Gastroenteritis

Asthma, 6 y.o.

Sickle Cell Crisis, 10 y.o.

Possible: Bronchiolitis

Tib-Fib Fracture, 16 y.o.

OB Scenarios

Endometritis

Term Newborn

Labor Admission

Postpartum Complication

Postpartum Assessment

Preeclampsia

Other topic not included in our library of cases:

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)

Please acknowledge each item below:

I understand I need to discuss the scenario with CSC faculty prior to schedule confirmation to ensure it is appropriate to the level of the learner and instructional need.
Requesting faculty will post CSC Admission Ticket on Learning Management System (D2L, Canvas, etc.) for students to access.
Very Important! Requesting faculty will ensure skills listed on the Admission Ticket are completed in skills lab prior to the simulation experience.

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