Section 1 of 6

About You

A few basics so we can tailor everything that follows.

Full Name *

Email Address *

Clinical Role *

Emergency Physician Family Physician (Emergency) Resident Nurse Practitioner Critical Care Physician Other

Years in Emergency / Acute Care Practice

Primary Practice Setting

Urban tertiary / academic centre Community hospital (with specialist backup) Rural or remote hospital (limited backup) Transitioning / returning to practice

Section 2 of 6

Simulation Experience

Helps us calibrate the pace and complexity of your session.

How much simulation training have you done in the past 3 years?

None 1–2 sessions (e.g. a course or workshop) Several sessions as a learner Regular simulation training I have facilitated simulation myself

How comfortable are you performing under observation or being coached in real time?

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2

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4

5

Not comfortableVery comfortable

Section 3 of 6

Procedural Skills

Select all procedures you want to work on. We will prioritize based on your goals.

Which procedures would you like to focus on? Select all that apply

Any other procedures or specific technical skills you want to work on?

Overall, how would you rate your procedural confidence in emergency settings?

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2

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4

5

Low confidenceHigh confidence

Section 4 of 6

Simulation Scenarios

Which clinical areas do you want to work through? We will build cases around your choices.

Select the clinical areas most relevant to your practice Select all that apply

Any other scenarios or clinical situations you want to work through?

How would you rate your confidence leading a resuscitation under pressure?

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2

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5

Low confidenceHigh confidence

Section 5 of 6

Your Goals

This is the most important section. Be as specific as you can.

What is the single most important thing you want to walk away with from this training? *

Is there a specific case or clinical moment that prompted you to seek this training? You don't need to share details. Even a general description helps us understand your context.

What does success look like for you at the end of training day?

Are you coming alone or with a colleague?

Solo With 1 colleague Small group (3–4 people)

Section 6 of 6

Logistics

Help us find a date that works and understand any constraints.

Preferred session format

Half-Day (approx. 4 hours) Full-Day Intensive (approx. 8 hours) Not sure yet

Approximate availability Months or date ranges that work for you

Anything else you want Dr. Segeren to know before your session?

Let's Build Your Session.