Task Trainer Reservation Form

Contact Information

Primary Contact Name*

Phone Number*

Additional Phone Number

Email Address*

Group/Department Name

Equipment Request (Please Select All That Apply.)*

Airway Heads (Adult & Peds) a. Intubation b. Airway Management c. Cricothyroidotomy
Ultrasound Trainers (Adult & Peds) a. Cardiac Ultrasound b. TEE c. POCUS d. EFAST e. OB/GYN
Intraossious Trainer a.IO Access
IV Start Arms a.IV Starts b.Blood Draws
Pelvic Trainers a. Pelvic Exam b. Pap Smear
Suture Pads a. Suturing
Foley Catheter Trainer a. Male Catheterization Training b. Female Catheterization Training
Central Line Trainer a. Central Line Placement b. Ultrasound Compatible
Lumbar Puncture Trainer (Adult & Peds) a. Ultrasound Compatible
Arterial Line Trainer a. Arterial Line Placement b. Blood Gas Sampling
Chest Tube Trainer a. Chest Tube Placement b. Ultrasound Compatible c. Pneumothorax Needle Decompression
Joint Injection Trainers a. Joint injection with feedback
Rectal Trainer a. Rectal Exam b. Prostate Exam

Will You Need A Sim Tech For This Session?*

Please note that sim tech availability is not guaranteed.

I Understand The Confirmed Times Will Include 30 Minutes Before And After The Requested Times*

Start Date*

Start Time*

:

End Date*

End Time*

:

Is This A Recurring Event? If So, Please List Additional Dates:

Please Give A Brief Description And Location Of Your Event (Include All Pertinent Equipment And/Or Adapters You Will Use):*

Additional Comments/Requests: