Standardized Patient Application
Name:
First Name
Last Name
Age:
Gender Identity:
Preferred Pronouns:
Cell Phone:
*
Email:
*
Street Address:
Apt.#:
City:
State/Zip:
Emergency Contact:
Contact's Phone #:
Availability (please select all that apply)
Monday 7AM - 12PM
Monday 12PM - 6PM
Tuesday 7AM - 12PM
Tuesday 12PM - 6PM
Wednesday 7AM - 12PM
Wednesday 12PM - 6PM
Thursday 7AM - 12PM
Thursday 12PM - 6PM
Friday 7AM - 12PM
Friday 12PM - 6PM
Employment, Skill, and Interest Items:
What is your current occupation?
How did you hear about the WUSM Program? Who were you recommended by? (if applicable)
Briefly describe your past experience and opinions about physicians and other medical care providers.
Please list any additional skills, knowledge, experience, or other information you would like to share that might be helpful to our program. (For example: teaching experience, languages spoken, involvement in community programs, CPR training, stage make up, etc.)
All students, faculty, staff, and independent contractors that work for Washington University must prove that they have received the Covid-19 vaccine. Please confirm below that you have been vaccinated. Please also let use know if you received the Covid-19 booster shot. Please note, if hired you will be required to show proof of both.
*
Yes, I've received the Covid-19 vaccine and can present my vaccination card upon request.
All students, faculty, staff, and independent contractors that work for Washington University must prove that they have received the flu vaccination. Please confirm below that you have been vaccinated. Please also let use know if you received the Covid-19 booster shot. Please note, if hired you will be required to show proof of both.
*
Yes, I have received the most recent flu shot and can present proof of vaccination.
Please upload a current professional portrait.
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All information is correct and complete.
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