The Office of Medical Simulation » Standardized Patient Recruitment WesternU HCOM

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Date(Required)

Identified Gender(Required)

Race(Required)

Date of Birth(Required)

How did you hear about WesternU's Standardized Patient Program?(Required)

Why are you interested in serving as a Standardized Patient?(Required)

What special skills, abilities, or experiences do you feel that you bring to this position?(Required)

Please describe any previous acting experience.(Required)

What languages, other than English, do you consider yourself fluent in?(Required)

How would you rate your computer literacy?(Required)

Not comfortable with computers
Somewhat comfortable with computers
Very comfortable with computers

Please describe any previous SP experience.(Required)

Please describe any previous experience in teaching, tutoring, coaching, or evaluating (formally or informally).(Required)

Without divulging any personal medical details, please briefly describe your feelings regarding and previous experience with physicians and other healthcare providers.(Required)

Would you be comfortable having a basic, non-invasive physical exam performed on you?(Required)

Yes
No

Would you be comfortable performing in a hospital gown and undergarments and lifting/lowering the gown in order for students to properly perform certain examinations? (listening to heart, lungs, abdomen, etc).(Required)

Yes
No

Would you be comfortable performing while being video and audio recorded? (recordings used solely for educational purposes and will never be released to the public).(Required)

Yes
No

Do you or have you worked in healthcare? If yes, what is/was your role?(Required)

Yes
No

Describe your role.(Required)

Please list any physical findings, scars, or other conditions that might impact your ability to portray a specific role (surgery scars, heart murmur, vision or hearing impairments, limited joint movement, etc.).(Required)

Standardized Patients are usually needed Monday through Friday 7:30 AM - 12:00 PM, 12:30 PM - 5:00 PM, or 7:30 AM to 5:00 PM. Do you have any scheduling limitations (example: part-time job, school, family obligations)? If so, please describe.(Required)

Yes
No

Please describe any scheduling limitations.(Required)

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