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NAME

Institutional Affilitation

Institution Name

Health Profession Program Name

Address

City

State

Country

Phone Number

Email Address

How do you plan to use the C-ICE©?

Research
Student Competency
Resident Competency
Practitioner Competency
Other (if chosen please provide an explanation below)

What environment do you plan to use the C-ICE©

Didactic Course activity
Simulation activity
Service learning activity
Clinical Practice

Would you be willing to share your results with us?

Yes
No
Not Sure

Would you be interested in collaborating on future projects related to the instrument's use?

Yes
No
Not Sure

If you would like to have your future publication (describing use of the C-ICE© tool) included in our citation list, please email LindsayIverson@creighton.edu

If you require assistance and support in case you encounter any issues or have questions about using the instrument properly, please contact LindsayIverson@creighton.edu

Would you be interested in collaborating to align the C-ICE to the updated IPEC competencies?

Yes
No

Please use the area below for any additional questions/comments, your question/comment will be automatically emailed to Dr. Lindsay Iverson, APRN, ACNP-BC Associate Professor Creighton University at lindsayiverson@creighton.edu

Terms of Use Agreement:

I understand that I have been granted permission by the creators of the C-ICE© to use the C-ICE© for academic and/or research purposes.

I confirm that I will complete the required training prior to the use of the C-ICE©. In addition, I agree that all individuals working with the C-ICE© will also complete the required training prior to using the instrument.

I understand that I may be asked to share results on any validity or reliability as determined by the creators of the C-ICE©.

I understand and agree with all parts of the Terms of Use Agreement