Penn Medicine Clinical Simulation Center Session Planning Worksheet Survey

Thank you for your scheduling request at the Penn Medicine Clinical Simulation Center. In order to best serve your group please answer the questions below to the best of your ability, completing this form at least two weeks prior to your event.

To ensure a prompt response to your request, please email SimulationCenter@uphs.upenn.edu to let us know you have requested a training session. This email can also be used to address any questions you might have.

This form should not be used to register for ACLS, PALS or BLS courses. That must be done through Knowledge Link.

1. Proposed Course Title:

Proposed Course Title:

2. Proposed Course Date(s):

Proposed Course Date(s):

3. Proposed Course Time(s):

Proposed Course Time(s):

4. Sponsoring Department:

Sponsoring Department:

5. Faculty/Instructors to Provide Training:

Faculty/Instructors to Provide Training:

6. Your Name and Contact Information:

Your Name and Contact Information:

7. Contact in Event of Scheduling Issue (if same as above please indicate this):

Contact in Event of Scheduling Issue (if same as above please indicate this):

8. Number of Students to Attend Session:

Number of Students to Attend Session:

9. Type of Learner/Participant:

Type of Learner/Participant: Residents Nurses SOM Students	Faculty Allied Health
Other, please indicate type:

10. Session Learning Objectives:

Session Learning Objectives: 1
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3
4
5
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8

11. Please list the metrics you will monitor to determine the effectiveness of this session. (Reduced length of stay, Infection rate, etc ):

Please list the metrics you will monitor to determine the effectiveness of this session. (Reduced length of stay, Infection rate, etc ): 1
2
3
4
5

12. Which of the Imperatives in the FY13 Penn Medicine Blueprint for Quality and Patient Safety will this training address (may be more than one).

Which of the Imperatives in the FY13 Penn Medicine Blueprint for Quality and Patient Safety will this training address (may be more than one). Accountability for Perfect Care

Patient and Family Centered Care

Transitions in Care/Coordination of Care

Reducing Unnecessary Variations in Care

Provider Engagement, Leadership, and Advocacy

13. Location of Training:

Location of Training: Penn Medicine Clinical Simulation Center

In Situ (On the Floor)