USA STANDARDIZED PATIENT APPLICATION
Name
*
First Name
Last Name
Middle Initial
Preferred name
Todays date
*
/
Month
/
Day
Year
Date
Street Address
*
City
*
State
*
Zip code
*
Email
*
example@example.com
Birthdate
*
/
Month
/
Day
Year
Date
Jag#, if known (students, employees)
Gender
*
Cell phone
*
Format: (000) 000-0000.
Home phone (if different)
Format: (000) 000-0000.
Are you a U.S. citizen?
*
YES
NO
If NOT a U.S. citizen, do you have a U.S. social security number?
YES
NO
If NOT a U.S. citizen, have you created a university Glacier profile?
YES
NO
How (or from whom) did you hear about our program?
Are you currently enrolled as a student?
*
YES
NO
If YES - Where?
If YES - What is your major?
Are you enrolled in the USA School of Nursing?
*
YES
NO
If yes, which semester? (1, 2, 3, 4, or 5 only)
Are you employed with the University of South Alabama (also including USA University Hospital, USA Providence Hospital, or 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 worked as a Standardized Patient before?
*
YES
NO
If YES, where?
Briefly describe yourself:
*
Briefly describe your past experiences with - and opinions of - physicians and other medical care providers:
*
What special skills/abilities/experiences do you feel you could bring to your work as a Standardized Patient?
*
Do you have any experience working in the healthcare field?
*
YES
NO
If YES, in what capacity?
Please list any languages spoken other than English:
What are some of your hobbies/special interests?
How would you rate your comfort level on a computer?
*
Not comfortable
Somewhat comfortable
Very comfortable
Why do you want to be a Standardized Patient? (check all below that apply)
*
Monetary compensation
Educational experience
Personal growth
Theatrical enhancement
I've heard it is fun/interesting
If there any other reasons, please explain here:
Are you comfortable with a student performing a physical examination* on you, similar to what you may experience at your doctor's office? *This may include respiratory, dermatologic, musculoskeletal, cardiovascular, EENT, or neurological exams. It will NEVER INCLUDE blood sampling, injections, invasive exams - breast, genitourinary, gynecologic, prostate, rectal,etc.
*
YES
NO
Comments regarding physical examinations, if needed:
Do you live in Mobile all year round?
YES
NO
Other
If you have class (students) or other jobs/responsibilities that will affect your availability, please mark the times you are NOT AVAILABLE (in class, at work, other commitments): ***If you are using a phone, you may need to TURN IT SIDEWAYS (landscape) to make sure you see all weekday options.
Rows
Mon
Tues
Wed
Thurs
Fri
8am - 9am
9am - 10am
10am - 11am
11am - 12noon
12noon - 1pm
1pm - 2pm
2pm - 3pm
3pm - 4pm
4pm - 5pm
Notes related to your availability, if needed:
0/150
You may contact us at simulation@southalabama.edu with any questions about our program.
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