Nursing Skills Practice/Simulation Request Form

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Nursing Skills Simulation Lab

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Skills Lab Simulation Request

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Health Sciences Information and Admissions Office
Eastview Campus
Building 8000, Room 8356
3401 Webberville Road
Austin, TX 78702
Phone: 512.223-5700 or
toll-free 888.626-1697
E-mail:
healthsciences@austincc.edu

Nursing Skills Practice/Simulation Form

Date of Request:		Lab Topic(s):
Day & Date of Lab:		Time:
Course Name and #:		Instructor:
Instructor Email Address:
Number of Students: Number of Setups :
Goal:
Objective:
Purpose:	Skill Practice Check Off Comp/Mastery Simulation
Supplies Requested:
Beds and Mannequins Needed:
Simulation Request
Patient Profile/Patient Name:
Patient Reaction:
Agenda:
Items Needed:

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