Campus Which VCOM Campus are you applying as a Standardized Patient for? Virginia Campus Carolinas Campus Auburn Campus Louisiana Campus Personal Information First name Last name Street address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Email address Cell phone Home phone Work phone Birth year Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Gender Female Male Race/ethnicity Emergency Contact Information Emergency Contact Name Emergency Contact Phone Number Relationship to Emergency Contact Current or past occupation Are you a US citizen? Yes No Do you own a computer? Yes No Do you have access to email? Yes No Do you currently smoke? Yes No Have you ever been a Standardized Patient? Yes No Are you related to a VCOM student? Yes No Are you a close friend of a VCOM student? Yes No As part of a role would you be willing to have students palpating your skin, listening to your heart and lungs, etc? You will NEVER be asked to have a genital, rectal, breast or pelvic exam in our program. Yes No Do you have any tattoos or piercings? Yes No If so, where? How would you rate your level of comfort using a computer? - None -Not comfortable at allSomewhat comfortableVery comfortable How did you hear about our Standardized Patient program? Why are you interested in the Standardized Patient program? Please specify any medical problems for which you are currently being treated. Please disclose any scars, irregularities, or special medical conditions that might enhance or impede your ability to portray specific roles. What days and hours are you available for training and testing?