Standardized Patient Case Request

Standardized Patient Case Request
Please submit your request 4-6 months in advance of your event. We will review your request and get back to you in a week or so with the next steps in the planning process.

We look forward to working with you!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
School / Department / Organization*
Course / Name*
Schedule
Desired Date(s)*
Alternative Date(s)*
Event Logistics
Event Format (check all that apply). Note: A typical SP event would three have parts: a pre-brief, an in-person encounter and a debrief*

In-personTelemedicineMulti-StationInterprofessional Education (IPE)PrebriefDebriefOther
Location*

Simulated Outpatient SettingOther
Virtual tour of the Simulated Outpatient Setting.
Equipment and Supplies (check all that apply)*

SimulationiQ VideorecordingTask TrainerUltrasoundOther
Please describe Task Trainer.*
What is the purpose of the Ultrasound?*
Case Details
Case Title*
Case Author or Source*
Patient Name(s)*
Chief/Presenting Concern/Reason for Visit*
Differential Diagnosis*
Final Diagnosis*
Case Objective*

FormativeSummativePracticeDemonstrationOther
Case Challenges (check all that apply)*

Patient CounselingDifficult PatientBad newsEmbedded Simulation Participant (ESP). Note: A person other than the patient there to provide the learner more information (i.e., case adversary or patient advocate).Other
Psychological Safety Warnings (uncomfortable case content)*
Learner Details
Learner Affiliation*

Undergraduate Medical EducationGraduate Medical Education (Residents, Fellows)School of Health ProfessionsAffiliate HospitalExternal to BCMOther
Who are the learners? (Check all that apply)*

MS1MS2MS3MS4PGY-1PGY-2PGY-3PGY-4PGY-5PGY-6PGY-7PGY-8FellowsFacultyPA StudentOP StudentGC StudentDNP StudentAdvanced Practice ProviderOther
How many learners will participate?*
How many learners will observe?*
Learning objectives? *
Intended Learner Tasks (check all that apply)*

HistoryPhysical ExamCommunication SkillsManagement PlanCounselingMotivational InterviewingOther
Intended Learner Assessment (check all that apply)*

ChecklistPENVPP (assessed by SFM)Data Interpretation (e.g., SAMS, EKG, Imaging)QuizFormative/No AssessmentOther
Psychological Safety Warnings (uncomfortable case content for learners)*
Standardized Patient (SP)Details
SP Role (check all that apply)*

Role Player. Note: The SP should imagine they are in a particular situation and behave exactly as they feel they would; no case development, assessment, or script is requiredStandardized Patient. Note: Individuals who are trained to portray a patient with a specific condition in a realistic, standardized and repeatable way; case development and a script are requiredSimulated Faculty Member (SFM)Embedded Simulation Participant (ESP)Other
SP Demographics/Recruitment Guidelines
Gender Identity*

Cisgender MaleCisgender FemaleTransgender (male to female)Transgender (female to male)No PreferenceOther
Patient Age*
Acceptable Age Range for Portrayal*
Race/Ethnicity*
Physical Description: Height Range*
Physical Description: Proportional Weight*

AnyUnderweightAverageOverweightObese
Physical Limitations (e.g., incompatible scars or piercings)*
Psychological Safety Warnings (uncomfortable case content for SPS)*
Funding
How will this activity be funded?
Note: At this time, there is no charge for events that serve BCM learners and trainees.
Administrator for billing
Payment Method (e.g., BCM Cost Center, Check, PO#, Credit Card)
Note: Payment is not processed at the time of request.
Please provide any additional details
Attach files if applicable

Cancelof
Should be Empty:

Standardized Patient Case Request

Schedule

Event Logistics

Case Details

Learner Details

Standardized Patient (SP)Details

SP Demographics/Recruitment Guidelines

Funding