Standardized Patient Request

Use this form if your event will NOT be held at the Clinical Skills Center.

To request Standardized Patients for an event that will be at the CSC, please use the Facility Reservation Request Form.

Use this form to request Standardized Patients only.

Your name*
First Last
Department
University email*
Campus phone
Will contact be on-site during event?*
- Yes
- No (If no, please provide information for the event day, on-site contact below)
Name of event day, on-site contact
First Last
On-site, Day-of contact email
On-site, Day-of contact phone number(for urgent contact on day of the event, if SP is lost or having difficulty entering a locked building)
Worktag for event*
Briefly describe your event and what the Standardized Patients will be doing. If this is an ultrasound, please indicate what parts of the body are involved and whether or not the SP or SPs need to be NPO. If NPO yese, provide instructions*
Describe any required training.
Desired date and timeframe of event (please provide multiple options if possible) Please indicate the actual start time. If this is an ultrasound event, we will add a 15-minute SP arrival buffer. For all other events, we will add a 30 minute SP arrival buffer.*
Event location*
Expected number of participants
Educational/professional level of participants
- Medical students
- Interns/Residents/Fellows
- Faculty
- Nursing/Nurse Practitioner students
- Other
If you selected "Other," please describe.
Number of SPs needed
Age Range of SPs
Gender of SPs(specify if any is acceptable)
Please describe any exclusionary characteristics (e.g. surgical scars)
Questions or comments