• Personal/Background Information

  • Date Format: MM slash DD slash YYYY
  • Indicate feet and inches (example: 5 ft. 3 in)
  • (pounds)
  • Ethnic Background

  • Current Mailing Address

  • Note: In order to work in this program, you must have a telephone with answering machine or voicemail that you check regularly.
  • Communicating by email is preferred–to send you roles, make changes to roles, check schedules, etc.
  • Current Medical Status

    Your personal health status and experiences will impact your standardized patient portrayals. Please answer the following questions briefly to help us best match your characteristics to our curriculum needs.
  • SurgeryDate 
  • Availability (Select All that Apply)

  • MondayTuesdayWednesdayThursdayFriday 
    Please indicate "morning," "afternoon," and/or "full day" under each day.
  • Types of Experiences (Select All That Apply)

    The Burrell College of Osteopathic Medicine needs SPs for many types of learning and testing situations. You will not be asked to participate in any type of examination you are not comfortable with. Please indicate which of the following types of educational experiences you would be willing to participate in:
    (You will NEVER be asked to have a genital, rectal, breast or pelvic exam in our program.)