Please enter your full name, as you entered it on the initial application form.
What would you like to be called during the course? (This name will appear on your course name badge.)
Please enter the email address that you used on the initial application form. You will receive a confirmation email with your responses when you submit this form.
What is your job title or current role?
e.g. Associate Program Director, Fellow in Medical Simulation, Clinical Nurse Specialist, Program Manager of Simulation, Staff Development Specialist
What is your primary discipline?
Here we are looking for answers like nurse, physician, allied health professional behavioral scientist, non-clinical educator.
What is your clinical specialty?
Clinical examples might be anesthesia or emergency medicine.
A non-clinical example might be organizational behavior.
For applicants who are no longer practicing clinically, please tell us your previous clinical background.
Please state your native language and additional any languages in which you feel comfortable conversing. In some courses, we have break out groups in languages other than English.
Briefly tell us about your professional experience, educational background, and any relevant educational activities you have completed over the past 5 years.
Prerequisites: To be eligible for this course, participants must have previously taken either the Comprehensive Instructor Workshop or Simulation as a Teaching Tool Workshop. Individuals who have not taken either course may apply for an exemption if they can demonstrate significant debriefing experience and expertise. Please contact Jenny Rudolph to request an exemption.
Have you taken one of these Simulation Instructor Training courses or will you before the Advanced Instructor Course (AIC) begins?
Since you have not previously completed (or plan to complete) one of CMS' Simulation Instructor Training courses, we need to evaluate your debriefing skills to determine if this course will benefit your practice. The best way for us to do this is to watch a recording of one of your debriefings. This step is required for us to consider you for acceptance into the course.
By selecting yes below, you agree to:
Please indicate which CMS Simulation Instructor Training courses you have previously completed or plan to complete before this course begins You can select more than one answer.
NOTE: The AIC begins March 1
Approximately when did you or will you complete the Comprehensive Instructor Workshop in Boston? Please indicate the Month and Year of the course if possible (e.g. April 2013).
Approximately when did you or will you complete the Gateway Debriefing Skills Workshop? Please indicate the Month and Year of the course if possible (e.g. April 2013).
Approximately when did you or will you complete the Operating Room Teams Instructor Course in Boston? Please indicate the Month and Year of the course if possible (e.g. June 2014).
Approximately when did you or will you complete the Simulation as a Teaching Tool course? Please indicate the Month and Year of the course if possible (e.g. October 2013).
Approximately when did you or will you complete a DASH Rater Training Workshop or Webinar? Please indicate the Month and Year of the course if possible (e.g. April 2015).
Approximately when did you or will you complete an Advanced Instructor Course (formerly known as the Graduate Course)? Please indicate the Month and Year of the course if possible (e.g. May 2014).
Approximately when did you or will you complete an Advanced Debriefing Course? Please indicate the Month and Year of the course if possible (e.g. February 2014).
To review or edit your previous responses, click on the Previous button below.
We understand that you are familiar with the basics of debriefing. When responding to the following question, please reflect on your recent debriefing experiences.
When you consider your debriefing skills, please list two or three aspects of your repertoire that you would like to work on in this course.
We would like to better understand your goals for taking the course. Goals could relate to content you desire to learn, skills you would like to improve, the process or flow of the course, connecting with peers and faculty, a problem you want help with, or something else.
What are your goals for the course?
In one module of the course, you and two or three other participants will run a scenario with other peers as participants, debrief them, and receive feedback on both the scenario and debriefing. You will also participate as learners in a scenario and debriefing with your colleagues. Your answers here will help us match you with colleagues for these group activities.
We would like to understand how important it is to you to practice running a scenario that you have developed versus assisting in the running of one of your peer's scenarios.
How important is it for you to run a scenario? Please select from the following options:
The question below pertains to a scenario that you might like to run in the course. If you indicated that you are very interested in running your scenario and are selected as a scenario team leader, we will ask you to submit a detailed description of your scenario later. We will provide you with faculty coaching in advance of the course and technical assistance onsite for running your scenario.
Please keep in mind:
Since you will be running the scenario on your peers, an ideal scenario will be challenging and meaningful to participants from any clinical specialty. Although only one scenario will be used per group, we need to know what everyone in the course would ideally like to run so that we can tailor scenario groups to your needs. If you usually run scenarios on medical or nursing students, consider how the scenario might be adjusted to provide a challenge to your peers in this course.
In the text area below, please provide a 2-4 sentence overview of the scenario you might like to run in the course so we can understand the gist of your scenario. You will have an opportunity to provide more specific details of your scenario later.
We need to know the following information:
NOTE: We recommend that you compose your responses offline and copy/paste them here. You may lose what you've written if you compose a long description here.
Please provide a 2-4 sentence overview of the scenario you might like to run in the course here:
To improve your debriefing and your ability to reflect on the impact of your own frames, we ask you to write and submit a rich debriefing case. This case could recount a difficult debriefing situation you have encountered, or a repeated, unwelcome dynamic you experience in your own debriefing. You will be recreating dialogue from memory or from a recording of one of your own debriefings. You and your peers will analyze your case in detail during the on-site workshop to help you improve your debriefing skills.
In the course, your debriefing case is referred to as a Two Column Debriefing Case. This case is likely different from the debriefing you will do as part of your group's scenario.
Learner-driven activities guided by your interests. On the last day of the course, there is time set aside for participants to design and offer learning activities or groups to establish support or bet practices. These activities are organized and run by participants in the course on topics of interest to them.
Learner-driven sessions emerge organically during the course and/or some of you may have ideas, even before arriving that you would like to propose and invite others in the course to join. If you think you might like to lead or find collaborators to lead a session, our faculty can work with you ahead of the course to leverage your time on site if you provide us some detail now. (This is optional)
Brief Session Idea
In the text area below, please provide a 2-4 sentence overview of the session you might like to create or run in the course so we can understand the gist of your session. You will have an opportunity to provide more specific details of your workshop later.
We need to know the session topic overview.
Please provide a 2-4 sentence overview of the workshop session you might like to run in the course here:
You will have opportunities to get structured consulting from Center for Medical Simulation Faculty on moving your simulation agenda forward. There is no problem too small or too large—our goal is to help you analyze it and identify the next steps in implementation. In the past, participants have sought help on such topics as:
If you would like help with such a problem our faculty can work with you ahead of the course to refine your problem statement so as to leverage your time on site if you provide us some detail now. (You can also utilize this consulting help without doing this advance work; refining your problem statement in advance is optional).
In the space below, please describe the strategic challenge you face or goal you would like to reach:
To submit your responses to the Admissions Committee, click on the Submit button below.
The Center for Medical Simulation is approved by the American College of Surgeons (ACS) as a Level 1-Accredited Educational Institute and is endorsed by the American Society of Anesthesiologists (ASA).