Standardized Patient Questionnaire

Date:

CalendarToday

Name:

Do you have a nickname or preferred way to be addressed?

Address:

City:

State:

Zip:

Home Phone:

( ) - Second three digits Last four digits

Work Phone:

( ) - Second three digits Last four digits

Cell Phone:

( ) - Second three digits Last four digits

Email:

Please indicate the best method of daytime contact:

Would e-mail correspondence be a reliable form of daytime contact for you?

Availability: (please check all that apply) These are generally Monday through Friday business hours with some ‘long days.’ We will do our best to be flexible to fit your needs.

Mornings (7:00 am -12:00 pm):

 

 Anytime (7:00 am - 6:00 pm):

 

  Afternoons (12:00 pm -5:00 pm):

 

 Other:

 

What age range could you portray?

How did you hear about the Standardized Patient Program?

Why are you interested in working as an SP?

Describe your personality (10 words or less):

What special skills/abilities/experience do you feel you might bring to this position?

Briefly describe your past experiences with, and opinions of, physicians and other medical providers:

What does diversity, equity, and inclusion mean to you and why are they important?

Any additional information you feel we may find helpful?

Please tell us if you are interested in learning more about these other areas where we use SPs:

I am interested in more information regarding the PSR (prostate, scrotum, rectum) examination program:

Yes:

 

 No:

 

I am interested in more information regarding the C/B&VVUA (chest/breast and vulva, vagina, uterus, adnexa) examination program:

Yes:

 

 No: