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Standardized Patient Program Application
Home
Standardized Patient Program
Standardized Patient Program Application
Standardized Patient Program Application
Jeff Harris
2020-07-10T11:37:45-06:00
Name
*
First
Last
Email
*
Communicating by email is preferred–to send you roles, make changes to roles, check schedules, etc.
Enter Email
Confirm Email
The phone number where we can best contact you:
*
Note: In order to work in this program, you must have a telephone with answering machine or voicemail that you check regularly.
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
*
MM slash DD slash YYYY
Languages Spoken:
Why are you interested in working as a Standardized Patient?
*
Please list any related qualifications (theatre, teaching, communications, etc.):
*
Have you worked as an SP before?
*
Yes
No
If so, where?
If so, have you been trained to delivery learner feedback?
Yes
No
Are you able to provide written and/or oral feedback to medical students in a positive, sensitive, constructive, and helpful manner?
*
Yes
No
Highest Level of Education:
*
Less than High School
High School or Equivalent
Associate Degree
Bachelor's Degree
Graduate or Professional Degree
Some College
Prefer Not to Answer
Other
Medical Training:
*
How comfortable are you with using a computer and email?
*
Do you have reliable transportation?
*
Yes
No
How did you hear about our program?
*
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.
Ethnicity :
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic of Latino
Native Hawaiian or Other Pacific Islander
White
Prefer Not To Answer
What is your gender:
*
Male
Female
Prefer To Self Describe
Prefer Not to Say
Prefer To Self Describe:
Are you willing to provide your height and weight?
*
Yes
No, I would prefer not to say.
Height
*
Indicate feet and inches (example: 5 ft. 3 in)
Weight
*
(pounds)
Are you willing to provide some health information?
*
Yes
No, I would prefer not to say.
Please list physical findings (surgical scars (including C-section scars), heart murmur, etc.):
*
Illnesses, Surgeries, Hospitalizations (please add dates if possible):
*
This information is obtained to help avoid any potential injuries to participating Standardized Patients during events.
Are you willing to participate in Physical Exam sessions (shoulder exam, neck exam, etc.)?
*
Yes
No
Are you willing to be in a hospital gown (wearing shorts and woman wearing a sports bra) and be examined by medical students?
*
Yes
No
Are you willing to have physical exams performed on you (heart, lung, abdominal, ears, eyes, throat, neurologic, etc.)?
*
Yes
No
Are you willing to participate in ultrasound training (soundwaves generated to render images of the internal organs, believed to be harmless)?
*
Yes
No
Are you willing to be able to be video recorded while these encounters are taking place?
*
Yes
No
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.
Are you comfortable in role- play situations around a set of given and specific case material? Even if the situations are emotionally charged, such as those dealing with terminal illness, death, or loss issues?
*
Yes
No
Availability (Select All that Apply)
Please indicate your availability to work as an SP:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Please indicate "morning," "afternoon," and/or "full day" under each day. Note: Most SP Events occur between 8:00AM - 6:00PM Monday through Friday
Signature
*
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
*
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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X
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