Standardized Patient Application Form (Adult) Survey

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* 2. Personal Information

First Name & Last Name

Address

Postal Code

City

Primary Phone Number

Secondary Phone Number

Email Address

Date of Birth (MM/DD/YYYY)

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* 3. What age range do you think you can convincingly play? (e.g. early 20s - mid 30s)

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* 4. Please upload a recent selfie / photo of yourself (we do not need headshots, just make sure it looks like you on a regular day)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 5. Are you a UVic employee?

Yes

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* 6. Do you have any dietary restrictions or allergies?

Yes

If you answered "yes", please elaborate

The following questions are for identification and casting consideration. We need as much information as possible to ensure we are casting appropriately.

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* 7. Which of the following describes your present gender identity?:

Trans Man

Trans Woman

Non-Binary

2Spirit

Bigender

Genderqueer

Cisgender Man

Cisgender Woman

I identify as (Please specify below)

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* 8. My assigned sex at birth was:

Male

Female

Intersex

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* 9. My pronouns are:

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* 10. Do you consider yourself to be part of any of the following communities / groups?

2SLGBTQIA+

d/Deaf

Disability

ESL (English as a Second Language)

Hard of Hearing

Immigrant

Blind or low vision

Other (please specify)

N/A OR Prefer Not to Answer

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* 11. What is your cultural background (check all that apply)

African

European

East Asian

First Nations or Indigenous (please specify below)

Hispanic or Latinx

Middle Eastern

South Asian

South East Asian

Other (please specify below)

Prefer not to answer

Other or First Nations/Indigenous (please specify)

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* 12. What race would you identify yourself as? Check all that apply

Black

East Asian

Hispanic / Latinx

Indigenous

Middle Eastern

Pacific Islander

South Asian

South East Asian

White / Caucasian

Don’t know

Prefer not to answer

Other or Specify if applicable / desired

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* 13. In order to help us match you with a patient case, please provide us with the following information:

Height:

Weight:

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* 14. List any distinguishable medical findings that you may have, such as a heart murmur, any surgical scars or benign conditions (e.g. psoriasis or eczema), diabetes, arthritis, chronic pains:

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* 15. Are there any accessibility needs or requests that you would like to share?:

The following questions will help us identify your suitability (experience, availability, any conflicts of interest) for the SP Program

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* 16. How did you find out about the Standardized Patient Program? Please be specific:

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* 17. Why are you interested in participating in the Standardized Patient Program?

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* 18. Have you worked as a Standardized Patient before?

Yes

If yes, please state where and what types of roles you have done:

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* 19. Do you have any experience acting, teaching, coaching, or public speaking

Yes

If yes, please provide specifics

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* 20. Are you or any friends/family studying medicine or pre-med at IMP or elsewhere?

Yes

If yes, please specify their name and year of study

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* 21. Do you plan to pursue a career in any of the following health professions (check all that apply)

Medicine

Nursing

Physiotherapy

Dentistry

Pharmacy

None of the above

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* 22. Is your availability flexible with notice?

Yes

Sometimes

If you answered "sometimes", please elaborate:

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* 23. Our program sessions and exams (where you would be performing as a Standardized Patient) take place on weekday afternoons and six Saturdays/year from 7:30am - 3:30pm. Do you have any availability conflicts within this schedule?

Yes

Sometimes

If you answered "sometimes", please elaborate:

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* 24. Our training sessions occur on weekdays, and depending on availability we may hold trainings that run until approximately 7pm on weekdays or the occasional weekend day. Are you available for evening and occasional weekend trainings (2hrs max)

Yes

Sometimes

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* 25. When would you usually be available to train?

	Morning	Midday	Afternoon	Early Evening
Monday	Monday Morning	Monday Midday	Monday Afternoon	Monday Early Evening
Tuesday	Tuesday Morning	Tuesday Midday	Tuesday Afternoon	Tuesday Early Evening
Wednesday	Wednesday Morning	Wednesday Midday	Wednesday Afternoon	Wednesday Early Evening
Thursday	Thursday Morning	Thursday Midday	Thursday Afternoon	Thursday Early Evening
Friday	Friday Morning	Friday Midday	Friday Afternoon	Friday Early Evening
Saturday	Saturday Morning	Saturday Midday	Saturday Afternoon	Saturday Early Evening
Sunday	Sunday Morning	Sunday Midday	Sunday Afternoon	Sunday Early Evening

Other (please specify)

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* 26. Are you willing to participate as an SP for a physical exam? This may be an exam of extremities such as neck, shoulder, back, knee, legs, ankle, abdomen (i.e. stomach), or chest (i.e. listening to your heart or lungs). You would be appropriately gowned or dressed, and there would always be another individual present during the exam. There are no sensitive exams (eg. genitalia).

Yes

It Depends

If you answered "it depends", please elaborate:

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* 27. Do you have any other comments or information that you feel would be helpful to your application?

Certain medical histories can have a direct impact on a student’s ability to assess our Standardized Patient cases successfully (e.g. an undisclosed appendix removal scar). By checking this box, you agree that you have done your best to disclose any/all relevant medical information. All disclosed information will remain confidential

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* 28. I agree to keep IMP updated on my medical information.

Yes

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* 29. Personal information (“Information”) provided on this application form is collected pursuant to section 26 of the Freedom of Information & Protection of Privacy Act, R.S.B.C. 1996, c.165. The Information will be used for the purposes of administering the Standardized Patient Program within the Island Medical Program (IMP) at the University of Victoria (UVic). I have read and understand the above. I consent to the use of my Information as outlined above for the duration that I am involved with the IMP Standardized Patient Program at UVic.

Yes

IF YOU ARE UNDER THE AGE OF 19, AUTHORIZATION BY YOUR PARENT AND/OR LEGAL GUARDIAN IS REQUIRED. This form will need to be printed and signed by parent/legal guardian and then scanned to sptrainer@uvic.ca or faxed to the Island Medical Program: ATTN Patient Programs at Fax # 250-519-1549. Alternatively, you can request a fillable PDF by emailing sptrainer@uvic.ca

This information will be used for the purposes of administering the Standardized Patient Program within UBC's Island Medical Program at UVic. Information will be shared with relevant departments on a need to know basis. If you have any questions regarding collection of information, please contact:

Sammie Gough

Patient Programs Coordinator

Island Medical Program

Royal Jubilee Hospital – Coronation Annex (Room 105)

1952 Bay Street, Victoria, B.C., V8R 1J8

Tel: 250-370-8111 ext. 12386

Email: patientprograms@uvic.ca

Jonathan Brower

Patient Programs Trainer

Island Medical Program

Royal Jubilee Hospital – Coronation Annex (Room 106)

1952 Bay Street, Victoria, B.C., V8R 1J8

Tel: 250-661-0075 (cell)

Email: sptrainer@uvic.ca

Standardized Patient Application Form (Adult)

Question Title

* 1. Date

Question Title

* 2. Personal Information

Question Title

* 3. What age range do you think you can convincingly play? (e.g. early 20s - mid 30s)

Question Title

* 4. Please upload a recent selfie / photo of yourself (we do not need headshots, just make sure it looks like you on a regular day)

Question Title

* 5. Are you a UVic employee?

Question Title

* 6. Do you have any dietary restrictions or allergies?

Question Title

* 7. Which of the following describes your present gender identity?:

Question Title

* 8. My assigned sex at birth was:

Question Title

* 9. My pronouns are:

Question Title

* 10. Do you consider yourself to be part of any of the following communities / groups?

Question Title

* 11. What is your cultural background (check all that apply)

Question Title

* 12. What race would you identify yourself as? Check all that apply

Question Title

* 13. In order to help us match you with a patient case, please provide us with the following information:

Question Title

* 14. List any distinguishable medical findings that you may have, such as a heart murmur, any surgical scars or benign conditions (e.g. psoriasis or eczema), diabetes, arthritis, chronic pains:

Question Title

* 15. Are there any accessibility needs or requests that you would like to share?:

Question Title

* 16. How did you find out about the Standardized Patient Program? Please be specific:

Question Title

* 17. Why are you interested in participating in the Standardized Patient Program?

Question Title

* 18. Have you worked as a Standardized Patient before?

Question Title

* 19. Do you have any experience acting, teaching, coaching, or public speaking

Question Title

* 20. Are you or any friends/family studying medicine or pre-med at IMP or elsewhere?

Question Title

* 21. Do you plan to pursue a career in any of the following health professions (check all that apply)

Question Title

* 22. Is your availability flexible with notice?

Question Title

* 23. Our program sessions and exams (where you would be performing as a Standardized Patient) take place on weekday afternoons and six Saturdays/year from 7:30am - 3:30pm. Do you have any availability conflicts within this schedule?

Question Title

* 24. Our training sessions occur on weekdays, and depending on availability we may hold trainings that run until approximately 7pm on weekdays or the occasional weekend day. Are you available for evening and occasional weekend trainings (2hrs max)

Question Title

* 25. When would you usually be available to train?

Question Title

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* 27. Do you have any other comments or information that you feel would be helpful to your application?

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* 28. I agree to keep IMP updated on my medical information.

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