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OUWB Standardized Patient Program Application
Please provide your responses to the following:
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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/
DD
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YYYY
Sex
Height *
Your answer
Weight *
Your answer
Address *
Your answer
Email Address *
Your answer
Telephone Number *
Your answer
Alternate Telephone Number
Your answer
Preferred method of contact? *
What interests you about being a Standardized Patient? *
Your answer
What attributes do you feel you would bring to this Standardized Patient Program? *
Your answer
How did you hear about this program? If through a personal referral, may we contact that person? *
Your answer
In your own words, what is the job description of a Standardized Patient? *
Your answer
Some roles or scenarios require students to perform limited physical examinations. Are you comfortable allowing students to examine you? *
Please list all medical conditions, scars, piercings, and/or tattoos you have which might be noticed during a physical exam. *
Your answer
If you or someone you know has had a recent experience (good or bad) with a health care professional, please describe that experience. *
Your answer
Which of the following best describes your employment status? *
Please select all answers that apply. What is your current week day work availability? *
Required
Please select all answers that apply. During which of these time periods are you available to work?
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