Simulation Case Information

1. Author:  


2. Title:  


3. Topic:  


4. Would you like this case to be submitted for peer review?
   Yes
   No  
5. Keywords:
    


6. Primary contact email address:  
 

7. Institution:  


8. Are you willing to have your email address attached to this file so that others may contact you regarding this case and its use?
   Yes
   No  
9. This case was designed for:
   Evaluation
   Education
   Evaluation and Education
   Research  
10. Target Audience:

    (Please check appropriate audiences for this simulation, and then estimate the number of times the case has been run for that group. Zero (0) is an acceptable answer if the case is proposed for, but has not been run for this group.)

    Medical Student		Nursing Student		EMT-B
    Resident		Nursing Assistant		Paramedic
    Fellow		Technician		Other Pre-Hospital
    Attending Physician		RN		Lay Professional

11. Version Number (whole numbers only):
     
12. Simulator Details:
    

    Age:

    Gender:  Male Female Any

    Chief Complaint:

    Diagnosis:

13. Description of simulation:
    
14. Usage notes:
    
15. Hardware required:
    
16. Setting:
    
17. Actors required:
    Yes
    No
    If yes, please list roles/requirements:
    
    
18. This case contains a timeline of events, transitions, or some depiction of the flow of the case: Yes
    No
19. This file contains an evaluation tool (e.g. a checklist): Yes
    No

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