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.
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)
Only 5th semester nursing students are accepted to be SPs.
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 (you are 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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