Requirements for Standardized Patients

George Washington University School of Medicine and Health Sciences Clinical Learning and Simulation Skills Center

Project Participant Information
Information is used for project participation recruitment only.

* Legal First Name
Legal Middle Name
* Legal Last Name
Stage Name (optional)
* Address
* City
* State
* Zip Code
* Email Address
Home Phone (xxx) xxx-xxxx
* Cell Phone
* Have you ever been paid by GW?
* Have you ever been a student at GW?
* Birth Date (mm/dd/yyyy)
* Height
* Weight
Ethnicity (For Recruitment Purposes Only)
American Indian/ Alaska Native
Black or African American
Native Hawaiian/ Pacific Islander
* Gender
* Are you a U.S. Citizen?
Do you have a Visa to work in the U.S.?
Please indicate the languages spoken.
Please list all your education and training.
Do you have any prior SP work?
If yes, please list where?
* Are you a member of an actor union?
If yes, which one(s)?
* Do you have any scars?
If yes, please indicate location(s)?
* Do you have any tattoos?
If yes, please indicate location(s)?
Please indicate your general availability?
  Morning Afternoon Evening
At which campus are you available to work?
* GW School of Medicine and Health Sciences,
Washington DC
* GW School of Nursing Ashburn, Virginia
Please list any conditions you have that could be discovered during a routine physical exam (i.e. heart murmur, use of hearing aids, enlarged thyroid, insulin pump, prosthesis, high blood pressure, skin problems, arthritis, reduced lung capacity, etc.)
* Would you consider having or learning to teach pelvic/rectal or prostate/rectal exam for educational purposes?
* How did you hear about this program?
Additional Comments?
* Upload Headshot: