The Office of Medical Simulation » Standardized Patient Recruitment COMP-Northwest

Name*

First Last

Address*

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

Phone*

Email*

Date*

Identified Gender*

Race*

Date of Birth*

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?*

Please describe any previous acting experience.*

What languages, other than English, do you consider yourself fluent in?*

How would you rate your computer literacy?*

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

Please describe any previous SP experience.*

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

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

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

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).*

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).*

Yes
No

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

Yes
No

Describe your role.*

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.).*

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.*

Yes
No

Please describe any scheduling limitations.*

To ensure that you receive future communications about job recruitment, please add spnw@westernu.edu to your email address book. Otherwise, our email communications to you may be sent to your email junk mail box.