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Standardized Patient Program Application

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  • Standardized Patient Program
  • Standardized Patient Program Application
Standardized Patient Program ApplicationJeff Harris2020-07-10T11:37:45-06:00
  • Communicating by email is preferred–to send you roles, make changes to roles, check schedules, etc.
  • Note: In order to work in this program, you must have a telephone with answering machine or voicemail that you check regularly.
  • Date Format: MM slash DD slash YYYY
  • The following information is obtained on a voluntary basis and solely for educational purposes. Any information provided is not obtained using HIPAA compliant software. The activities/examinations that you may partake in are instructional only and are not to be considered professional medical advice, diagnosis, or treatment. The supervising physician and/or learner does not replace your primary care physician, always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
  • Indicate feet and inches (example: 5 ft. 3 in)
  • (pounds)
  • This information is obtained to help avoid any potential injuries to participating Standardized Patients during events.
  • All Exams are non-invasive. You will NEVER be asked to have a genital, rectal, breast or pelvic exam in our program. Note: all exams are recorded in order to assure accuracy and for the student review. All recordings are kept confidential and remain the sole property of Burrell College of Osteopathic Medicine. Images stripped of identifying features may be used by the College for medical education or research purposes.
  • Availability (Select All that Apply)

  • MondayTuesdayWednesdayThursdayFriday 
    Please indicate "morning," "afternoon," and/or "full day" under each day. Note: Most SP Events occur between 8:00AM - 6:00PM Monday through Friday
  • I have answered these questions truthfully and honestly and I am aware of the requirements of being an SP. I therefore feel comfortable with what I would be expected to do. (Note: You can use your mouse/touch screen to sign)
  • Date Format: MM slash DD slash YYYY
  • *Please bear in mind that standardized patients are contracted as needed, based on the educational and experiential requirements of our medical students. We will contact you when a project appropriate for you arises, and you will be required to attend at least one comprehensive training session prior to each learning event you are assigned.
    *By signing this form, you acknowledge that the Standardized Patient activities do not in any way constitute a clinical or doctor-patient relationship and you agree to hold the Burrell College of Osteopathic Medicine, its employees and students harmless from any and all claims, losses, or damages related to the Standardized Patient activities as well as any costs associated with related medical care and/or treatment. You further acknowledge that your participation is voluntary and you have read this document, are signing it freely and understand the legal consequences, including (a) releasing the stated releasees from all liability, (b) waiving your right to sue the releasees, (c) and assuming all risks of participating in these activities, including travel to and from the activities and any events incidental to such activities.

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Burrell College of Osteopathic Medicine
3501 Arrowhead Dr
Las Cruces, NM 88001
Phone: 575.674–BCOM (2266)
Fax: 575.674.2267

 

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