Fill in the appropriate information and click submit

Clinical Skills Center Survey

Fill in the appropriate information and click "Submit."

Center name:
College/University:		State/Province:
Address:		Country:
City:		Zip:
Contact:		Phone:
Email:		Fax:

What year was the center built?
What is the square footage of the center?
How was the center financed?
What is the source of the operating budget for the center?
Who controls the over all operation and management?

Staff/Job titles:
Director			SP Trainer
Clinic Manager			SP Coordinator



Equipment
(click all that apply)
Exam table			Manufacturer:
Sphygmomanometer			Manufacturer:
X-Ray view box			Manufacturer:
Oto/Ophthalmoscope			Manufacturer:
Desk			Bulletin board
Sink			Dry erase board
Chairs			Other:



Audio, Visual, and Monitoring Equipment
(click all that apply)
Video Cameras	How many per room:
Wide angle lens	Zoom Lens	Microphones
VCR	Intercom System	Monitors with real time (viewing & tape replay)
Monitors with tape replay only
Other:



Center Operations
Do you use a computerized scheduling system?		Yes No
If yes, what software do you use:
In no, what do you use:

Security Measures:
(click all that apply)
Electronic Alarm	Guard
Motion Detector	Lock/Key/Card entry


Do you use plastic models?			Yes No
	If yes, for which exams:

What types of patients do you use?			Simulated/Standardized Real
		Other:

Additional Comments:

Please feel free to send attachments with pictures, floor plans, blue prints, etc. to be included with your center's information. Send attachments in a separate e-mail to Marilyn Fulper.