eSIM Provincial Participant Evaluation
Demographic Questions
Booking Number
*
If your booking number includes eSIM with just four numbers please enter a leading '0' (eSIM1234 would be entered as eSIM01234)
Primary Facilitator Name
*
What is your professional designation?
*
Please Select
Nursing
Respiratory Therapist
Allied Health - All professional designations outside of RTs
HCA
Physician
Nurse Practitioner
Undergraduate Student
Medical Student
EMS
Resident/Fellow
Dentist
Dental Assistant
Admin/Clerical
Protective Services
Other
What Zone are you Located?
*
Edmonton
Central
Calgary
South
North
North Zone
Athabasca Community Health Services
Barrhead Healthcare Centre
Bonnyville Healthcare Centre
Edson Healthcare Centre
Grande Prairie Regional Hospital
High Prairie Health Complex
Hinton Healthcare Centre
Lac La Biche Healthcare Centre
Northern Lights Regional Health Centre
Peace River Community Health Centre
Wabasca Healthcare Centre
Westlock Healthcare Centre
Whitecourt Healthcare Centre
Other, please specify
Edmonton Zone
Alberta Hospital Edmonton
Devon General Hospital
Edmonton General Hospital
East Edmonton Health Centre
Fort Saskatchewan Community Hospital
Glenrose Rehabilitation Hospital
Grey Nuns Community Hospital
HSERC
Leduc Community Hospital
Lois Hole Hospital for Women
Misericordia Community Hospital
Northeast Community Health Centre
Royal Alexandra Hospital
Strathcona Community Hospital
Sturgeon Community Hospital
UAH - Cross Cancer Institute
UAH - Kaye Edmonton Clinic
UAH - Mazankowski Heart Institute
UAH - Stollery Children's Hospital
UAH - Walter Mackenzie Centre
Villa Caritas
Westview Health Centre
Other, please specify
Central Zone
Camrose (St. Mary's Hospital)
Drumheller Health Centre
Olds Hospital & Care Centre
Ponoka Hospital & Care Centre
Provost Health Centre
Red Deer Regional Hospital Centre
Sundre (Myron Thompson Health Centre)
Three Hills Health Centre
Wetaskiwin Hospital & Care Centre
Other, please specify
Calgary Zone
Airdrie Urgent Care
Banff Mineral Springs Hospital
Calgary Cancer Centre
Canmore
Cochrane
Foothills Medical Centre
High River
Okotoks
Peter Lougheed Centre
Richmond Road Diagnostic Treatment Centre
Rockyview General Hospital
Sheldon Chumir Urgent Care
South Health Campus
South Urgent Care
Strathmore
Other, please specify
South Zone
Bassano
Brooks
Cardston
Chinook Regional Hospital
Crowsnest Pass
Fort McLeod
Medicine Hat Regional Hospital
Milk River
Pincher Creek
Raymond
Taber
Other, please specify
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Learning Objectives
After the session I feel more confident in my ability to....
*
Strongly Agree (5)
Agree (4)
Neutral (3)
Disagree (2)
Strongly Disagree (1)
Not Applicable
Participate as a leader or follower.
Delegate or be receptive to direction.
Understand my role and fulfil my responsibility within an interprofessional team.
Recognize a change in clinical status or deteriorating condition.
Work collaboratively with patients and families to improve experience.
Communicate effectively by addressing members directly, repeating back and seeking clarity.
Refer to established protocols and checklists for the procedure/intervention.
Know when and how to seek additional resources.
Please check the box that best reflects your rating:
*
Strongly Agree (5)
Agree (4)
Neutral (3)
Disagree (2)
Strongly Disagree (1)
Not Applicable
The goals and objectives of this session were clear and met.
The content and topics were relevant to my educational needs.
I am confident that I can apply the knowledge and skills that I learned today.
The simulation session will help improve patient safety.
Quality of the Facilitation
Please check the box that best reflects your rating:
*
Strongly Agree (5)
Agree (4)
Neutral (3)
Disagree (2)
Strongly Disagree (1)
Not Applicable
The facilitator set the stage with the pre-brief and maintained an engaging context for learning.
The post-scenario debriefing was helpful for my learning.
The facilitator(s) structured the debriefing in an organized way.
The facilitator(s) set and maintained a respectful and psychologically safe environment.
Quality of the Simulation Session
Please check the box that best reflects your rating:
*
Strongly Agree (5)
Agree
(4)
Neutral (3)
Disagree (2)
Strongly Disagree (1)
Not Applicable
The overall educational experience of the simulation event was excellent.
The simulation scenarios content and debriefing were appropriate for my practice and specialty.
The facilities, equipment and setting of the simulation was appropriate.
This simulation event was well organized and effective use of my time.
The content presented in the simulation session was evidence informed (i.e. scientifically balanced).
Yes
No
Please expand on any key learnings from today's simulation session and areas for improvement.
Question ONLY for Physicians
Please indicate which CanMEDS roles you felt were addressed during this educational activity (select all that apply):
*
Medical Expert
Communicator
Collaborator
Leader
Health Advocate
Scholar
Professional
Did you perceive any degree of commercial or inappropriate bias in any part of the simulation program?
Yes
No
Is this an accredited simulation activity, in which CPD Credits may be claimed? (If unsure, please check with your facilitator)
*
Yes
No
Do you require a certificate for your participation in the simulation today?
Yes
No
Please Select the Simulation Activity:
Please Select
Calgary Emergency Department Staff Simulation Program
Calgary Zone Diagnostic Imaging Simulation Program
David Schiff NICU
Edmonton Zone Emergency Department Annual Simulations
Edmonton Zone Neonatal Emergency Resuscitation in the Emergency Department (ED)
Edmonton Zone Trauma Program Annual Simulations
Fort Saskatchewan Community Hospital Emergency Department Simulation
FMC NICU Simulation Program
Grey Nuns Emergency Department Simulation
Indigenous Themed Simulation
Misericordia Perioperative Simulation Program
Phillip C. Etches NICU RST Simulation
PLC Hospitalists Simulation Program
Quality Improvement/SIS (Unaccredited)
Rural Emergency Department Simulation Program
Rural Perioperative Simulation Program
SHC Anesthesia/Surgical Simulations
SHC Hospitalists Simulation Program
Southern Alberta Neonatal Transport Service (SANTS) Outreach Simulation
Stollery Pediatric Emergency Staff Simulation
Strathcona Community Hospital Emergency Department Simulation
WestView Emergency Department Simulation
Urgent Care Simulations
Hours of Participation
Section
Submit
Should be Empty: