Standardized Patient (SP) Screening/Recruitment Form

General Information

Name:

Street Address:

City:

State:

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Zip:

Phone #:

Email Address:

Availability (Days of Week/Times):

Are you a Stony Brook employee?

Yes

No

Were you ever a Stony Brook employee?

Yes

No

Are you a student at SUNY Stony Brook?

Yes

No

Grad Date:

Your major?

ID#:

Are you a full/part time matriculated student enrolled for the current semester?

Yes

No

How did you hear about the Clinical Skills Center SP Program? Indicate name of reference:

Another Standardized Patient

Faculty

Employee

Website

Other, please list

Enter name:

Where do they work?

Other, please list:

Background

Occupation/Current Employer:

Educational Level (select highest degree):

H. S. Diploma

Associate"s Degree

Bachelor"s Degree

Post Graduate Education (MS, PhD, etc.)

Major/Field:

Computer Skills:

Basic

Intermediate

Advanced

Related Experience: (ex. clinical experience, theater, role play, teaching experience, communication skills)

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