URMC / Institute for Innovative Education / Center for Experiential Learning / Simulation / Standardized Patient Program / How to Become a Standardized Patient / Standardized Patient Questionnaire Standardized Patient Questionnaire place field "Date" below Date place field "Name" below Name place field "DoYouHaveANicknameOrPreferredWayToBeAddressed" below Do you have a nickname or preferred way to be addressed? place field "Address" below Address place field "City" below City place field "State" below State place field "Zip" below Zip place field "HomePhone" below Home Phone place field "WorkPhone_1" below Work Phone place field "CellPhone" below Cell Phone place field "emailinput" below Email place field "PleaseIndicateTheBestMethodOfDaytimeContact" below Please indicate the best method of daytime contact place field "Would_e_mail_correspondence_be_a_reliable_form_of_daytime_contact_for_you__" below Would e-mail correspondence be a reliable form of daytime contact for you? place field "Mornings__7_00_am__12_00_pm_" below Availability: (please check all that apply) These are generally Monday through Friday business hours with some ‘long days.’ We will do our best to be flexible to fit your needs. Mornings (7:00 am -12:00 pm) place field "Anytime__7_00_am___6_00_pm__" below Anytime (7:00 am - 6:00 pm) place field "Afternoons__12_00_pm__5_00_pm_" below Afternoons (12:00 pm -5:00 pm) place field "Other" below Other place field "WhatAgeRangeCouldYouPortray" below What age range could you portray? place field "HowDidYouHearAboutTheStandardizedPatientProgram" below How did you hear about the Standardized Patient Program? place field "WhyAreYouInterestedInWorkingAsAnSP" below Why are you interested in working as an SP? place field "DescribeYourPersonality_10WordsOrLess" below Describe your personality (10 words or less) place field "WhatSpecialSkills_abilities_experienceDoYouFeelYouMightBringToThisPosition" below What special skills/abilities/experience do you feel you might bring to this position? place field "BrieflyDescribeYourPastExperiencesWith_AndOpinionsOf_PhysiciansAndOtherMedicalProviders" below Briefly describe your past experiences with, and opinions of, physicians and other medical providers place field "ExtArea" below What does inclusive, welcoming, patient-centered care look like to you, and why is it important? place field "AnyAdditionalInformationYouFeelWeMayFindHelpful" below Any additional information you feel we may find helpful? place field "Yes" below Please tell us if you are interested in learning more about these other areas where we use SPs:I am interested in more information regarding the PSR (prostate, scrotum, rectum) examination program: Yes place field "No" below No place field "Yes_1" below I am interested in more information regarding the C/B&VVUA (chest/breast and vulva, vagina, uterus, adnexa) examination program: Yes place field "No_1" below No List any specific days/times you are not available Yes No:
