Fillable Liberty University Standardized Patient Application

Fill Online, Printable, Fillable, Blank Liberty University Standardized Patient Application Form

Use Fill to complete blank online LIBERTY UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Liberty University Standardized Patient Application

On average this form takes 13 minutes to complete

The Liberty University Standardized Patient Application form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Liberty University

BROWSE LIBERTY UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Center for Standardized Patients and Simulation
Standardized Patient Application
All responses included below are kept Confidential by the Center
Name: Gender:
Female Male
Date:
xx/xx/xxxx:
Address: (If using a P.O. Box, you need to also list your residential address)
Date of Birth:
xx/xx/xxxx
Home
Telephone:
Business
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: pjwatson1@liberty.edu
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Liberty University Standardized Patient Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 April 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document