STANDARDIZED PATIENT APPLICATION

Last Name

First Name

M.I.

Date

J# (If applicable)

Street Address

City

State

ZIP

Email Address

Mobile Phone

Home or Work Phone

Are you a U.S. Citizen

Yes No

If no, are you legally qualified to work in the U.S.?

Yes No

Age

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 USA Medical Center 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?

**Please save as a .pdf and email a digital copy of your application to usasp@southalabama.edu.**

Someone will contact you to set up an interview after your application is reviewed