STANDARDIZED PATIENT APPLICATION

STANDARDIZED PATIENT APPLICATION
Last Name
First Name
M.I.
Todays Date

MonthDayYear
Date
J# (If applicable)
Street Address
City
State
ZIP
Email Address
Mobile Phone
Home or Work Phone
Are you a U.S. Citizen

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

YesNo
Age
Gender
How or by whom did you hear about our program?
Briefly describe yourself
Are you currently enrolled as a student?

YesNo
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?

YESNO
If yes, where and in what position?
Have you ever been a standardized patient before?

YESNO
If yes, where?
Do you have any experience in the healthcare field?

YESNO
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 comfortableSomewhat comfortableVery comfortable
Why do you want to be a standardized patient? (check all that apply)

Monetary compensationEducational experiencePersonal growthTheatrical enhancementOther
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?

YESNOOnly when class is in sessionI 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?*

YESNO
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
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