Standardized Patient Program Application – Burrell College of Osteopathic Medicine Forms

Personal/Background Information

Name*

First Last

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Gender*

Male
Female
Non-Binary

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Date of Birth*

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Height*

Indicate feet and inches (example: 5 ft. 3 in)

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Weight

(pounds)

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Ethnic Background

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(Select One)

American Indian or Alaska Native
Asian
Black or African American
Hispanic of Latino
Native Hawaiian or Other Pacific Islander
White

Current Mailing Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The phone number where we can best contact you:*

Note: In order to work in this program, you must have a telephone with answering machine or voicemail that you check regularly.

Email*

Communicating by email is preferred–to send you roles, make changes to roles, check schedules, etc.

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Occupation*

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Retired?

Yes
No

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Highest Education Achieved:

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Hobbies/Recreation:

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Community Activities:

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Teaching or acting expertise:

How did you hear about the SP Program?

Why are you interested in the SP program?

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What special skills/abilities/experiences do you bring to the role of SP?

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Current Medical Status

Your personal health status and experiences will impact your standardized patient portrayals. Please answer the following questions briefly to help us best match your characteristics to our curriculum needs.

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List any surgeries you have had and the year(s) you had them:*

Surgery	Date

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List current medical conditions/ physical limitations you may have (Not required):

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Availability (Select All that Apply)

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Please indicate your availability to work as an SP:*

Monday	Tuesday	Wednesday	Thursday	Friday

Please indicate “morning,” “afternoon,” and/or “full day” under each day.

Which Burrell Campus are you applying for?*

New Mexico Campus
Florida Campus

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Types of Experiences (Select All That Apply)

The Burrell College of Osteopathic Medicine needs SPs for many types of learning and testing situations. You will not be asked to participate in any type of examination you are not comfortable with. Please indicate which of the following types of educational experiences you would be willing to participate in:

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Small group portrayals with 8-10 students and a faculty
Video-taped SP portrayals

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Fully clothed portrayals:

History taking
Sharing a personal medical experience
Health Counseling and Teaching

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Portrayals that require wearing a hospital gown (undergarments must be worn):

Non-invasive physical exams

(You will NEVER be asked to have a genital, rectal, breast or pelvic exam in our program.)