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| First | Last | Contact Email: | Contact Phone: | Facilitator Name | Facilitator Email | Facilitator Phone Number | Organization: | Other: | Which department? | Which unit? | Is there a research component? | If yes, please describe the research component and ethics approval: | Please indicate the location of the event | Please specify location | Is there a participant fee associated with this event? | Provide a brief description of your simulation activity. | If in-situ simulation, has a partnership pathway form been completed? | Please attach file | Has a needs assessment been performed? | Please attach file | Has a simulation session template been completed? | Please attach file | Is this an interprofessional event? (not mandatory question) | Expected number of learners | Expected number of simulation rooms required |
| First | Last | Contact Email: | Contact Phone: | Facilitator Name | Facilitator Email | Facilitator Phone Number | Organization: | Other: | Which department? | Which unit? | Is there a research component? | If yes, please describe the research component and ethics approval: | Please indicate the location of the event | Please specify location | Is there a participant fee associated with this event? | Provide a brief description of your simulation activity. | If in-situ simulation, has a partnership pathway form been completed? | Please attach file | Has a needs assessment been performed? | Please attach file | Has a simulation session template been completed? | Please attach file | Is this an interprofessional event? (not mandatory question) | Expected number of learners | Expected number of simulation rooms required |
