Revised Standardized Patient Information Form

KADO CLINICAL SKILLS CENTER
The Standardized Patient Program

Please Note:

We ask a number of questions regarding your demographics and health history. Any information provided will be used to help match you with appropriate case scenarios. All Information will be kept confidential.

Fields with asterisks (*) are required.

Demographic Information

First name *

Last name *

Email *

Address *

City *

State *

Zip Code *

Phone Number *

Gender *

Male

Female

Transgender

What is your birth year? *

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

How did you hear about the WSU-SOM SP Program? (If you heard about us from a friend, current SP, or WSU employee please provide name) *

Past Experience

Have you ever been a standardized patient before? *

Yes

If Yes, Where? (Please list name of University / facility / city / state / province & dates of employment)

If applicable, describe your background in either education or healthcare

If applicable, briefly describe your acting background.

Please tell us briefly about any positive or negative experience you have had with healthcare professionals *

What has been your experience with giving feedback? *

Briefly explain why you think you would make a good Standardized Patient *

Disclaimer and Consent

Are you willing to be digitally recorded during training and/or during performance encounters as a standardized patient? *

Yes

Are you willing to wear a hospital gown and be examined by healthcare professional learners? (You will NOT be required to endure any invasive procedures) *

Yes

How comfortable are you with role-playing? *

Very Comfortable

Somewhat Comfortable

Very Uncomfortable

Would you be able to stay "in character", as described in the given specific case material, while being interviewed and/or examined by healthcare professional learners even if they are struggling during their encounter? *

Yes

Not sure

Do you know anyone currently attending or planning to attend the WSU School of Medicine ? *

Yes

If Yes, list name and nature of your relationship to this person

We use email as our primary means of communication with our standardized patients (SPs). Please select the answer that best describes your level of computer use *

Use a computer daily for email and to browse the internet

Use a computer once or twice a week for email and to browse the internet

I avoid computers as much as possible

I do not have easy access to a computer

Do you have any significant scars, rashes, or conditions such as deafness, muscle weakness, heart murmur, etc. that would be obvious if a student examines you? *

Yes

If yes, please explain.

Please mark each day and time you would currently be available to work. Please only
mark times when you ARE available.

Mondays

Morning

Afternoon

Tuesdays

Morning

Afternoon

Wednesdays

Morning

Afternoon

Thursdays

Morning

Afternoon

Fridays

Morning

Afternoon

We are committed to ensuring accessibility for all guests. Please submit requests for any accommodations you may need