Standardized Patient Recruitment COMP-Northwest
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Date
*
MM slash DD slash YYYY
Identified Gender
*
Race
*
Select value
Asian
Black or African American
Hispanic
Middle Eastern
Native American
Native Hawaiian or Pacific Islander
Indian
White or Caucasian
Date of Birth
*
MM slash DD slash YYYY
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.