1. KidSIM Simulation Session Activity Report

* 1. Simulation Session Date

Please enter Simulation Session Date
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* 2. Please list number of participants for each discipline (if number is zero please leave blank)

* 8. What type of session took place?

* 9. Length of session
Please enter length in hours. (round up to nearest 30 mins)

* 10. Number of scenarios used for entire session (all labs)

* 11. Number of labs running concurrently (at same time)

* 12. What were the topics covered? (ie. sepsis, trauma, asthma, etc)

* 13. Were any of the following standardized elements included in the scenario?
Check all that apply.

* 14. Was the simulation session inter-professional?

* 15. Name of Facilitator(s):

* 16. Simulators Used?
Check all that apply.

* 17. Were there any issues with mannequins or other equipment?

* 18. Were any hazards identified in the simulation that may otherwise have gone unnoticed?

* 19. If yes to question 18 (above), was the hazard reported to:
Check all that apply.

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50% of survey complete.

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