Standardized Patient Recruitment
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
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
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):
Select value
Yes
No
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.
*
Not a student
COMP
COMP-Northwest
CAHP
COP
CGN
CVM
CDM
CO
CPM
GCBS
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