Standardized Patient Program Application Form

published by nicholas on Wed, 2011-11-23 22:21

Thank you for your interest in the Duke-NUS Graduate Medical School Singapore Standardized Patient Program. Please complete the following form to apply to be part of our program. Standardized Patients are hired as “on-call” part-time workers based on need. In addition to completing this application, please email any acting resume to: cpc@duke-nus.edu.sg.

You can find answers to many of the questions prospective applicants ask about the Standardized Patient Program here.

Personal Information

Salutation

NRIC/Passport Number *

Surname/Family Name *

Given Name *

Date of birth *

Year

Month

Day

Nationality

Ethnicity/Race

Religion

Contact Details

Postal Address *

Contact Numbers *

E-mail address *

Please upload a recent passport sized (400 pixel by 514 pixel ) photograph of yourself.

Your Interest in the SP Program:

1. How did you find out about the Duke-NUS Standardized Patient Program? (E.g.: Word of mouth, newspaper article, internet, etc)

2. What makes you interested in becoming a Standardized Patient? (Briefly explain)

3. Some Standardized Patients are needed for physical examinations. Are you comfortable wearing a hospital gown while a student

Yes

4. Upon hiring, you will be asked to complete a medical database form that will be used to better match you to specific Standard

Yes

5. What special skills do you think you will bring to this job?

6. Do you have any work experience that would be considered similar or applicable to this type of work?

Educational Background

Education Level

Have you studied medicine or have a background in healthcare?

Language Proficiency

Which language(s) can you read?

Minimal Level

Fluent Level

Which language(s) can you speak?

Minimal Level

Fluent Level

Computer literacy

Are you comfortable using a computer and a mouse?

Yes

Health Background:

Do you have any illnesses at the moment? (E.g.: Asthma, Diabetes, etc)

Yes

If YES, please specify:

Have you had surgery or an accident in the past that left a visible scar?

Yes

If you answered YES to the above questions, please specify the type of medical condition you have and/or the location and cause of any scars:

Employment History

Are you currently employed?

Yes

If YES, please specify

Please specify the days and the time slots you are available to work for the SP program.

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