1. KidSIM Simulation Session Activity Report

Simulation Session Date

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* 1. Simulation Session Date

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

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

What type of session took place?

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* 8. What type of session took place?

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

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

Number of scenarios used for entire session (all labs)

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

Number of labs running concurrently (at same time)

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

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

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

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

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

Was the simulation session inter-professional?

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* 14. Was the simulation session inter-professional?

Name of Facilitator(s):

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* 15. Name of Facilitator(s):

Simulators Used?
Check all that apply.

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* 16. Simulators Used?
Check all that apply.

Were there any issues with mannequins or other equipment?

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

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

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

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

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* 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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