Standardized Patient Program Application

Home
Standardized Patient Program
Standardized Patient Program Application

Personal/Background Information
Name*
First Last
Gender*
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Height*
Indicate feet and inches (example: 5 ft. 3 in)
Weight
(pounds)
Ethnic Background
(Select One)
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic of Latino
- Native Hawaiian or Other Pacific Islander
- White
Current Mailing Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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.
Email*
Communicating by email is preferred–to send you roles, make changes to roles, check schedules, etc.
Occupation*
Retired?
- Yes
- No
Highest Education Achieved:
Hobbies/Recreation:
Community Activities:
Teaching or acting expertise:
How did you hear about the SP Program?
Why are you interested in the SP program?
What special skills/abilities/experiences do you bring to the role of SP?
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.
List any surgeries you have had and the year(s) you had them:*
Surgery Date
List current medical conditions/ physical limitations you may have (Not required):
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.
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:
- Small group portrayals with 8-10 students and a faculty
- Video-taped SP portrayals
Fully clothed portrayals:
- History taking
- Sharing a personal medical experience
- Health Counseling and Teaching
Portrayals that require wearing a hospital gown (undergarments must be worn):
- Non-invasive physical exams
(You will NEVER be asked to have a genital, rectal, breast or pelvic exam in our program.)

Surgery	Date

Monday	Tuesday	Wednesday	Thursday	Friday

Watch Test

Standardized Patient Program Application

Personal/Background Information

Ethnic Background

Current Mailing Address

Current Medical Status

Availability (Select All that Apply)

Types of Experiences (Select All That Apply)