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SAIL Initial Consultation Form
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Email
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Your email
Todays Date:
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MM
/
DD
/
YYYY
Program Title:
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Your answer
Is this a new project or a renewal of an existing project?
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New
Renewal with changes (give specifics below)
Renewal without changes.
For "renewal projects," please specify what changes you are requesting.
Your answer
Anticipated date range for this program. Please note
projects may take up to 3 months to implement
:
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e.g. mm/dd/yyyy - mm/dd/yyyy
Your answer
Is this a one time event or a recurring event?
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One time
Recurring
If recurring, how often?
Your answer
Contact for program: Name, title, and role in this project
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Your answer
Who is the billing contact for this project?
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Your answer
What is the funding source for this project? (Please include FOPAL if applicable)
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Your answer
Department or Course:
Your answer
Project lead email:
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Your answer
Project lead phone:
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Your answer
Institution/Organization/Department
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Your answer
Who are the learners?
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Your answer
Primary purpose:
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Learning experience
Formative assessment
Summative assessment
Is this research?
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Yes
No
If so, please provide IRB approval info (type of consent data, retention plan, etc.), and research protocol:
Your answer
Tell us more about the project and what about this project is important to you?
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Your answer
List 3-4 Learning and/or Assessment Objectives: At the end of the program learner will be able to....
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e.g. 1.
2.
3.
4.
Your answer
Simulation modalities that might be used in this program:
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Simulated/Standardized Patients
Models for physical examinations or ultrasound
UTA/GTA
Task trainer models
Clinical findings simulators
High fidelity responsive mannequins
Other:
Required
Give us more logistical information about your vision of the project- number of encounters, types of encounters, etc.
*
Your answer
Additional comments
Your answer
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