ACCP Simulation Center

Please complete all fields of the submission form. The Simulation Task Force will have the initial review of all submissions. Allow 4 weeks to process your submission. If you should have questions regarding your submission or require assistance, contact Ed Dellert, RN, MBA, CCMEP at edellert@chestnet.org or at (847) 498-8333.

Thank you for completing the submission form.

* Required Fields
Submitter Information
First Name*		M.I.
Last Name*
Degree*
Title*
Place of Employment*
Street Address*
City*
State/Province*
ZIP/Postal Code*
Country*
Phone Number*
Fax Number*
E-mail Address*
Proposed Simulation Education Activity
Activity Title*
Keywords*	Select One Allergy and Airway Biotechnology Cardiovascular Disease Chest Infections Critical Care Critical Care Training Program Directors Cultural Diversity Diffuse Lung Disease Disaster Medicine Disorders of the Mediastinum Disorders of the Pleura Education and Teaching Genetic and Developmental Disorders Imaging Interventional Pulmonology Lung Cancer Lung Pathology Obstructive Lung Diseases Occupational and Environmental Lung Diseases Palliative Care and End-of-Life/Ethics Pediatrics Pediatric Chest Disease Practice Management and Administration Pulmonary Manifestations of Systemic Disease Pulmonary Physiology Pulmonary Rehabilitation Pulmonary Training Program Directors Pulmonary Vascular Disease Respiratory Care Signs and Symptoms of Chest Diseases Sleep Disorders Thoracic Surgery Tobacco Cessation and Prevention Transplantation
Keywords*	Select One Allergy and Airway Biotechnology Cardiovascular Disease Chest Infections Critical Care Critical Care Training Program Directors Cultural Diversity Diffuse Lung Disease Disaster Medicine Disorders of the Mediastinum Disorders of the Pleura Education and Teaching Genetic and Developmental Disorders Imaging Interventional Pulmonology Lung Cancer Lung Pathology Obstructive Lung Diseases Occupational and Environmental Lung Diseases Palliative Care and End-of-Life/Ethics Pediatrics Pediatric Chest Disease Practice Management and Administration Pulmonary Manifestations of Systemic Disease Pulmonary Physiology Pulmonary Rehabilitation Pulmonary Training Program Directors Pulmonary Vascular Disease Respiratory Care Signs and Symptoms of Chest Diseases Sleep Disorders Thoracic Surgery Tobacco Cessation and Prevention Transplantation
Clinical Needs Description *
Measurable Objectives
1.*
2.*
3.
Target Audience (please check all that apply)
Advanced Practice Nurses Cardiologists Cardio-Thoracic Surgery Critical Care Physicians Fellows-in-Training General Medicine		Physician Assistant Pulmonary Physicians Registered Nurse Respiratory Therapist Other
Educational Needs Assessment*
Purpose Evaluation Methodology*	Select One Pre & Post Test Checklist 360 Degrees Self-Assessment
Simulation Equipment Possibly Needed
Will you want video Recording for Debriefing? No Yes
Estimated Length of Course (please check ONE)
Chest Annual Conference (2 hours) 1 day (8 hours) 2 days (16 hours) 3 days (24 hours) Other
Proposed Faculty
Proposed Chair*
At least two faculty must be identified.
First Name*		M.I.
Last Name*
Street Address
City*
State/Province*
ZIP/Postal Code
Country*
Phone Number*
Fax Number*
E-mail Address*
Role*	Faculty  Chair
Subtopic Title*
Is this topic considered research or investigational?*
No Yes (If yes, please explain below)
Is there any potential financial conflict of interest for this faculty member?*
No Yes (If yes, please explain below)
First Name*		M.I.
Last Name*
Street Address
City*
State/Province*
ZIP/Postal Code
Country*
Phone Number*
Fax Number*
E-mail Address*
Role*	Chair   Faculty
Subtopic Title*
Is this topic considered research or investigational?*
No Yes (If yes, please explain below)
Is there any potential financial conflict of interest for this faculty member?*
No Yes (If yes, please explain below)
First Name		M.I.
Last Name
Street Address
City
State/Province
ZIP/Postal Code
Country
Phone Number
Fax Number
E-mail Address
Role	Chair   Faculty
Subtopic Title
Is this topic considered research or investigational?
No Yes (If yes, please explain below)
Is there any potential financial conflict of interest for this faculty member?
No Yes (If yes, please explain below)
First Name		M.I.
Last Name
Street Address
City
State/Province
ZIP/Postal Code
Country
Phone Number
Fax Number
E-mail Address
Role	Chair   Faculty
Subtopic Title
Is this topic considered research or investigational?
No Yes (If yes, please explain below)
Is there any potential financial conflict of interest for this faculty member?
No Yes (If yes, please explain below)

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