Standardized Patient Request

Please complete a separate form for each Standardized Patient (SP) you are requesting.

Course requests must be submitted in advance by the designated deadline dates posted on the G drive. Late requests will not be honored after the deadline except for emergency reasons (see emergency request form).

Simulation Location *

Simulation Location Healthcare Simulation Center Skills Lab Health Sciences Complex Other Other
Faculty Name Faculty Name * First Last
Faculty Email *
Course *
Date of Simulation Date of Simulation * / MM / DD YYYY
Time of Simulation *
Case Type *

Case Type History / Interview Physical Assessment Progressive Scenario Other Other

Select all that apply
Gender *

Gender Male Female Either
Acceptable Age Range *

Acceptable Age Range 18-25 26-35 36-45 46-55 56-65 66-76
Age Range Notes (if applicable)
Role of Standardized Patient *

Role of Standardized Patient Patient Family Member / Friend RN MD Emergency personnel Other Other
Additional Information (if applicable)

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