Standardized Patient Application Form

Memorial University Faculty of Medicine Learners

Standardized Patient Application Form

You are submitting an application to be considered for the CLSC Standardized Patient Program.  Please complete and submit the form by February 7, 2025. Everyone submitting a response will be contacted by the CLSC office by the end of March, 2025.

Protection of Privacy ‐ The personal information requested on this form is collected under the authority of Section 31(c) of the PEI Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of consideration for the Standardized Patient Program (SPP). Direct any questions about this collection to Katheryne Stewart, SPP Manager, at kathstewart@upei.ca or 902-620-5336.

Standardized Patient Form

1. Are you completing this form for yourself or on behalf of a minor child(Required)
3. Name(Required)
DD slash MM slash YYYY
6. What are your preferred pronouns?(Required)

9. Current Home Address(Required)
10. Where you previously employed by the University of PEI ?(Required)
11. The majority of Standardized Patient (SP) work takes place from Monday-Friday between the hours of 0800-1700. When are you most available?(Required)
12. Are there certain times of the year when you would not be available?(Required)
14. What is your current employment status?(Required)
15. Are you currently attending college or university?(Required)
17. Will you be applying to medical school in the next 12 months?(Required)
18. Are you legally entitled to work in Canada?.(Required)
19. Have you ever been discharged from work because your work or conduct was unsatisfactory?(Required)
20. Is there anything about your professional background or experience profile that makes you particularly well suited to being a Standardized Patient? If so, please feel welcome to share some brief details.
21. As mentioned in the SP information session, we will be building our SP program over years to come, onboarding new SPs twice annually. If you are not selected to become an SP at this time, would you be interested in keeping your name on our register for future contact?
SP Information session(Required)
22. As mentioned in the SP information session you attended, Teaching Patients are a different category from Standardized Patients. These are people who have a medical condition and would be willing to share their own medical histories, offering a unique learning opportunity for students. In their sessions, Teaching Patients meet 1:1 to share their own stories with students, and there is no role play involved. Note that children and adolescent SPs with medical conditions are also teaching patients, and they’re usually accompanied by a parent or family member during their sessions.
Would you be interested in becoming a teaching patient as well as an SP?(Required)
24. Please include two professional (or someone familiar with your professional behaviours) REFERENCES, including name, email address & telephone number.

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