STANDARDIZED PATIENT APPLICATION
Last Name
First Name
M.I.
Todays Date
/
Month
/
Day
Year
Date
J# (If applicable)
Street Address
City
State
ZIP
Email Address
Mobile Phone
Home or Work Phone
Date of Birth
Are you a U.S. Citizen
Yes
No
If no, are you legally qualified to work in the U.S.?
Yes
No
Gender
How or by whom did you hear about our program?
Briefly describe yourself
Are you currently enrolled as a student?
Yes
No
If yes, where and what is your major?
Are you employed with the University of South Alabama (including University Hospital and USA Children’s and Women’s Hospital) as a student worker or in any other capacity?
YES
NO
If yes, where and in what position?
Have you ever been a standardized patient before?
YES
NO
If yes, where?
Do you have any experience in the healthcare field?
YES
NO
If yes, in what capacity?
What special skills/abilities/experiences do you feel you bring to being standardized patient?
Briefly describe your past experiences with, and opinions of, physicians and other medical care providers
Please list languages spoken other than English.
What would you consider one of your leading strengths?
What would you consider one of your leading weaknesses?
What are your hobbies/special interests?
How would you rate your comfort level on a computer?
Not at all comfortable
Somewhat comfortable
Very comfortable
Why do you want to be a standardized patient? (check all that apply)
Monetary compensation
Educational experience
Personal growth
Theatrical enhancement
Other
Why do you want to be a standardized patient? (check all that apply)
If you are a student, do you reside in Mobile year round?
YES
NO
Only when class is in session
I go home holidays & summers
Are you comfortable with a student performing a physical exam* on you, similar to what you may experience at your doctor’s office?
*
YES
NO
ADDITIONAL
Is there anything else you would like to tell us about yourself?
STUDENTS ONLY:
Please tell us about your class schedule.
What Days/ Times ARE you IN CLASS?
Monday
Tuesday
Wednesday
Thursday
Friday
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
Someone will contact you to set up an interview after your application is reviewed
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