Standardized Patient Program Application

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 Country

Date of Birth*

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:*

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*

*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.

Watch Test

Standardized Patient Program Application

Availability (Select All that Apply)