Booking Information:
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For CSSC use only. Date:
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Time:
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College: Choose corresponding college. Click here to enter text.
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F= Enter # of female. M= Enter # of male.
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year Group: Click here to enter text.
Instructor Information:
Departmen t:
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society name is not mentioned above. Instructor’s name.
Specialty: Type here to enter text.
Session Details:
Session Title: Please provide the complete title of your session.
Learning Objective:
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Type of Session:
or
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Department:
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Booking Requested on:
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By providing name below, you are acknowledging that you have read, agreed to and accept the CSSC policy and procedures for learning education purposes. Our policy and procedures will be available on our
website and our front desk for reference.
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(In any case of any changes of booking info of session details or others, please provide information below) Name: Please provide complete name.
Comments: Type here your comments.
For inquiry, pls. contact ext.#: 14604, 14611
UF2-2017
Developed by: CSSC-KTA (26-04-17)
King Abdulaziz University Clinical Skills & Simulation
Centre
Utilization Form
Room No.: For CSSC use only
Type here to enter text.
Please see next page for the session requirements
** This is for CSSC use only Program Changes:
Date: Click here to enter a
date.
(Please specify reason): Type here to enter text.
Name: Please provide complete name.
Coordinator/Technician Name: (The one who will prepare for the session):Please provide complete name.
Educational Resources:
Please select for the I.T Items/Simulation Models required:
I.T Items Simulation Models
Other Simulation Models:
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
5. Click here to enter text.
For information on the following Manikins/Models, please refer to the Learning Resources Guide 1. AED Anne (page 30) 21. Sutures (pages 88, 90, 91, 94, 95)
2. CPR (Adult & Pediatric – pages 33, 34, 35,
36) 22. Diabetic Foot (page 98)
3. Choking Manikin (pages 32, 38) 23. IM Injection Model (page 93)
4. Kelly (page 43) 24. Naso Gastric Tube (page 98)
5. Wound Model (page 44) 25. Gastro+ING Tube Model (page 101) 6. Airway Management (pages 49, 51) 26. Gynecology Model (page 113)
7. Mechanical Ventilator (page 50) 27. Pelvic Examination Model (page 113
8. APW (APG) (page 55) 28. Bone Pelvic Examination Model w/Fetal Heads (page 118)
9. Lumbar Puncture (Adult & Pediatric – page
58) 29. Abdominal Examination Model (page 111)
10. Half of the Head (page 72) 30. Obstetric Model (page 114) For inquiry, pls. contact ext.#: 14604, 14611
UF2-2017
Developed by: CSSC-KTA (26-04-17)
11. Cardiology Patient (K+) (page 73) 31. Pregnancy Model (page 114)
12. Respiratory Machine (RES) (pages 73, 74) 32. Female Pelvic Organ/Anatomy (page 120)
13. Ear Examination (pages 82, 83, 86) 33. Skeleton (Full body, Foot, Spine, & Hand – page 140)
14. Eye Examination ( page 131) 34. Muscles of Legs and Hand (pages 140, 141) 15. IV Examination (page 96) 35. Type here to enter text.
16. Breast Model (Normal/Mass) (page 93) 36. Type here to enter text.
17. Lump Examination (page 89) 37. Type here to enter text.
18. Uro Catheter (pages 154, 155, 157) 38. Type here to enter text.
19. Rectal Examination (page 90) 39. Type here to enter text.
20. Hernia Model (page 92) 40. Type here to enter text.
For inquiry, pls. contact ext.#: 14604, 14611
UF2-2017
Developed by: CSSC-KTA (26-04-17)
