General Information Name: Street Address: City: State: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming 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) CAPTCHA Submit
