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  • Ohio State's College of Medicine
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Standardized Patient with Findings Application

Name *
Street Address *
City *
State *
Zip *
Gender *
Gender
Gender
Home phone
Work phone
Cell Phone
Are you interested in the SP program for patients with physical findings *
Are you interested in the SP program for patients with physical findings
Are you interested in the SP program for patients with physical findings
Please choose which physical findings you have *
Do you own a computer? *
Do you own a computer?
Do you own a computer?
How would you rate your level of comfort on the computer: *
How would you rate your level of comfort on the computer:
How would you rate your level of comfort on the computer:
How would you rate your level of comfort on the computer:
Do you have access to email? *
Do you have access to email?
Do you have access to email?
If yes, what your email address
Current Employer (if applicable)
Employer address
Employer phone
Are you a U.S. Citizen? *
Are you a U.S. Citizen?
Are you a U.S. Citizen?
Date of Birth *
Height (approx) *
Weight (approx) *
Ethnicity/Race *
Religion
Do you have reliable transportation? *
Do you have reliable transportation?
Do you have reliable transportation?
Have you ever been convicted of a felony? *
Have you ever been convicted of a felony?
Have you ever been convicted of a felony?
Have you ever been a Standardized Patient? *
Have you ever been a Standardized Patient?
Have you ever been a Standardized Patient?
If yes, where?
When are you available? Indicate all that apply *
Are you available year-round? *
Are you available year-round?
Are you available year-round?
How did you hear about our Standardized Patient Program? *
Why are you interested in the Standardized Patient Program?
Do you have any medical problems or conditions for which you are currently being treated? Please specify
Do you have any scars, irregularities or special medical conditions that might enhance or impede your ability to portray specific roles? Please specify
Please give a brief summary of your past medical history, including illnesses, hospitalizations, surgeries, chronic disease, etc.
Please list any medications you are currently taking.
Are you willing to allow trainees to perform a non-invasive physical exam? *
Are you willing to allow trainees to perform a non-invasive physical exam?
Are you willing to allow trainees to perform a non-invasive physical exam?
Are you willing to be part of a female (Breast or GYN) / Male (GU) exam? *
Are you willing to be part of a female (Breast or GYN) / Male (GU) exam?
Are you willing to be part of a female (Breast or GYN) / Male (GU) exam?
What is your highest level of education or training? *
What is your highest level of education or training?
What is your highest level of education or training?
What is your highest level of education or training?
What is your highest level of education or training?
What is your highest level of education or training?
What is your highest level of education or training?
Do you have any training or experience in the Health or Medical field? *
Do you have any training or experience in the Health or Medical field?
Do you have any training or experience in the Health or Medical field?
Are you familiar with medical terminology? *
Are you familiar with medical terminology?
Are you familiar with medical terminology?
Do you have any teaching experience in any context? if so, please specify
Please tell us about your hobbies, interests, community involvement, etc. *
Do you have additional skills, knowledge, or experience you think might be helpful to our program? Any other information you would like to give that might be helpful (health habits, activities, family, lifestyle, etc?)
(Professional reference) Name *
(Professional reference) Address *
(Professional reference) Telephone *
(Personal reference) Name *
(Personal reference) Address *
(Personal reference) Telephone *
I certify that all of the information furnished in this employment application is true and complete to the best of my knowledge. I understand that the university may investigate the information I have furnished. I authorize any person, firm or organization to supply any information about me concerning any past employment, military status, convictions, or other information to The Ohio State University and I further release any such person, firm or organization from any responsibility in disclosing such information, including from all liability for any damage that may result from furnishing such information to the University. The Ohio State University is a drug-free workplace. *
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