The Office of Medical Simulation » Standardized Patient Recruitment

Name*

First Last

Address*

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

Phone

Email*

Date*

Identified Gender:*

Race:*

How did you hear about WesternU's Standardized Patient Program?:*

Why are you interested in serving as a Standardized Patient?:*

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

Acting Experience (not required):

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

No
Yes

Describe your role

Do you have any medical conditions that we should be aware of? If yes, please explain:*

No
Yes

List medical conditions

Allergies (check all that apply):*

Cats
Dogs
Latex
Lotions
Makeup
Soap
Tape
Other

Please list any significant scars that we would need to consider for reasons of examination techniques for students in simulated/standardized cases? (Example: Chest scar from by-pass surgery)

Please list any diseases and/or conditions that you would rather NOT simulate.

Do you have children who may be able and interested in portraying cases? If so, what are their ages?*

No
Yes

List children's ages

There are several roles our Standardized Patient's work in. Please check any areas of interest.

Interviews with students (case memorization/acting)
Non-invasive physical exams with students (model-no case memorization)
Interviews and non-invasive physical exams with students
Pediatric non-invasive physical exams/interviews

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:*

No
Yes

List scheduling limitations

Are you currently a WesternU student? If yes, please select which college you attend.*

Please list three references with contact information (Name, Relationship, Phone, and Email Address)*

To ensure that you receive future communications about job recruitment, please add spoms@westernu.edu to your email address book. Otherwise, our email communications to you may be sent to your email junk mail box
**Please note that the University requires verification that you are legally authorized to work in the US and will conduct a criminal background check prior to employment