Standardized Patient/Participant Interest Form

Thank you for your interest in Belmont University’s Standardized Patient/Participant Program. The Center for Interprofessional Engagement and Simulation provides learning opportunities for students across the schools of medicine, nursing, pharmacy, occupational therapy, physical therapy, and social work, and the use of standardized patients in their education is paramount.  A standardized patient/participant (SP) is a person carefully recruited and trained to portray the roles of patients, family members, or others thereby allowing students to practice physical exam skills, history-taking skills, communication skills, and numerous other exercises. An interaction between a student and an SP may include any of the following:

- presenting case history in response to questioning by the student
- undergoing a limited physical examination at the student's direction
- wearing simulation devices that provide artificial symptoms and conditions
- the use of moulage or special effects makeup
- portraying potentially triggering emotional and mental states in a safe environment
- working alongside a manikin as a family member

SPs will also occasionally be asked to provide students with feedback, assisting students in developing their communication and clinical skills, and their ability to work through difficult emotional situations in a safe environment.

Once you complete this application, you may receive an email asking you to come in for an interview. Group interviews for prospective SPs are scheduled on an as-needed basis. Due to the amount of interest in our program, we are not able to employ all the talented individuals who contact us. SPs work on a project-by-project basis and may work anywhere from a few times a month to a few times a year.

There is no guarantee of work beyond what is agreed to on a single project basis. Belmont reserves the right to cancel a job; SPs will not be paid for canceled work unless the cancellation is less than 24 hours before the assigned arrival time.

SPs will be paid monthly at a rate of $25/hour.

A background check must be completed before working. (Belmont students are not required to complete a background check.)

A photo release must be signed before working, as all encounters will be filmed for both educational and safety purposes.

An Assumption of Risk and Release must be signed for insurance purposes.

Please fill out and sign the form below, indicating you have read and understand the above information.

Personal Information

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address (Please include any information needed for mailing your payment.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Potential SP Demographics

This information is extremely helpful, as some simulations will have specific requirements for the type of SPs we can use to make the situation as realistic as possible.

Age range you can portray*

Gender Identification*

Race/Ethnicity Identification*

Other languages you speak*

Please indicate any aspect of SP simulations you would NOT be comfortable with. This will not necessarily preclude you from being hired, as some SPs may only need to serve as a family member or other individual in a non-medical situation. Check ALL that apply (please note that all of these would be happening in a monitored and safe environment):*

Wearing a hospital gown with appropriate attire underneath (e.g. athletic shorts, sports bra)A non-invasive physical exam (e.g. listening to heart and lungs, testing reflexes, or other physical contact associated with a standard office visit)Wearing a simulation device (e.g. something small like a necklace that simulates heart and lung sounds or something larger like a false mid-section to simulate pregnancy)Wearing moulage or special effects makeupHeightened emotional scenarios where the patient may need to be calmed or restrainedNone of the Above

Please list any previous SP experience*

Please list any previous acting or related experience*

Please give a brief explanation of why you are interested in becoming an SP

Please Submit a Current Photo*

Please sign here to acknowledge that you have read and understand the provided information about our program and that the information you have provided to us is accurate.*