Center for Standardized Patients and Simulation
Standardized Patient Application
All responses included below are kept Confidential by the Center
Name: Gender:
Female Male
Address: (If using a P.O. Box, you need to also list your residential address)
Date of Birth:
Telephone: Cell Telephone: Reliable Vehicle?
Yes No
Ethnicity: Eligible for employment in the U.S.?
Yes No
Have you ever been convicted of a felony?
Yes No
Have you ever been named in a sexual
harassment or sexual assault case?
Yes No
Current Employer: Dates of Employment:
Highest level of education:
HS Diploma BA BS MA MS
MFA PhD Other
How many hours/week are you available to work? Morning, afternoon and/or evening?
Not Required: Height Not Required: Weight:
Not Required: Smoking history: #
packs/day # of years
Not Required: Current medications:
Not required: Please note any special or unusual items in your medical history:
E-mail address: Rate your proficiency utilizing a computer:
Incompetent: Can barely turn on
Proficient: Can email, fill out forms
Excellent: Bill Gates would be jealous
Health, Medical and/or Educational Training:
Teaching and/or Acting Experience (in any context):
How did you hear about this program? Please give name of contact if applicable.
What particular skills, experience or knowledge would you bring to this program?
Are you willing to be physically examined and wear a gown?
Yes No
WOMEN: Are you interested in teaching the
female pelvic exam?
Yes No Maybe
MEN: Are you interested in teaching the
male GU (testicular/prostate) exam?
Yes No Maybe
Please complete and either mail or e-mail application to the attention of Pamela Watson:
Liberty University College of Osteopathic Medicine
Center for Standardized Patients and Simulation
306 Liberty View Lane, Lynchburg, Va. 24502
Telephone: (434) 592-7661
Email address: