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
Suite/Floor
* City
* State
* Zip Code
* Email Address
Fax
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
Asian
Black or African American
Hispanic/Latino
Native Hawaiian/ Pacific Islander
White
Other    
* 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
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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: