Professional Development Center
Standardized Patient Information Form

Standardized Patient Information Form

Please provide as much information as possible.
* Indicates a required field.
Legal Name, as it appears on your Social Security Card.
Legal First Name:*
Middle Name:
Legal Last Name:*

E-mail Address:*
City:* State:* Zip code:*
Mobile/Primary Phone:*     Alternate Phone:    

1. How did you hear about our program?* (If referred by a current SP, please list their name):

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2. Do you know any UCSD medical students?*
Yes  No
3. Do you currently work for UCSD?*
Yes  No
4. Do you receive or have you received compensation (i.e. salary, cash, benefits, stipend, lodging) in any form from UCSD, outside of the Standardized Patient Program?*
Yes  No
5. Have you ever worked as an SP before?*
Yes  No
If yes, at what program or university and when?

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6. Do you have any acting or teaching experience?*
Yes  No
If yes, please give more information.

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7. Do you speak any languages, other than English, fluently? (Do not comment if your proficiency is only at a conversational level.)
8. Are you 18 years or older?*
Yes  No
9. Are you authorized to work in the U.S.?*
Yes  No
10a. Our students may conduct a focused physical exam on you. You may be required to dress in a hospital gown wearing only your undergarments. Students are NOT allowed to do pelvic, rectal, genital or breast (female) exams. Are you comfortable with this?*
Yes No
10b. Women Only: Would you be willing to be considered for roles which require you to be braless?
Yes  No
(We need to ask about any physical findings that a student might discover while examining you if you are hired to portray a case that includes a physical exam. All information is kept confidential.
11. Do you have any significant scars, rashes, tattoos, or conditions such as deafness, muscle weakness, heart murmur, high blood pressure, etc. that would be obvious if a student examines you during a physical exam?*
Yes  No

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Upload a head shot or photo:*  The photograph must be a jpg/jpeg
Upload a resume:  The resume must be a doc/docx/pdf/txt

The following information is VOLUNTARY, but would help us match you to specific patient roles:
Date of Birth (mm/dd/yyyy):  Gender:  Male  Female  Other
Height:  Weight: 
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