Simulated Participant Interest Form First Name Last Name Date of Birth Occupation Employer (if any) Gender - Select -ManWomanNon-binaryAgender/GenderlessAndrogyne/AndrogynousAporagenderBigenderDemi-agenderDemi-boyDemi-fluidDemi-girlDemi-genderDemi-non-binaryGenderqueerGenderfluxGenderfluidGender-indifferentGender-neutralGraygenderIntergenderMaveriqueMaxigenderMultigender/PolygenderNeutroisPangender/OmnigenderTrigenderTwo-spiritPrefer Not to Answer Height Weight Ethnic Background OtherCausasianAsianAfrican American / BlackHispanicMediterraneanOther other_ethnicity Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Day Phone Number Evening Phone Number Mobile Phone Number Email Address Best way to communicate during the day Telephone Email How did you hear about the SP program? Primary Language - Select -AfrikaansAmharicArabicAsturianAzerbaijaniBelarusianBulgarianBengaliTibetanBosnianCatalanCzechWelshDanishGermanDzongkhaGreekEnglishEsperantoSpanishEstonianBasquePersian, FarsiFinnishFilipinoFaeroeseFrenchFrisian, WesternIrishScots GaelicGalicianSwiss GermanGujaratiHebrewHindiCroatianHaitian CreoleHungarianArmenianIndonesianIcelandicItalianJapaneseJavaneseGeorgianKazakhKhmerKannadaKoreanKurdishKyrgyzLaoLithuanianLatvianMalagasyMacedonianMalayalamMongolianMarathiBahasa MalaysiaBurmeseNepaliDutchNorwegian BokmålNorwegian NynorskOccitanPunjabiPolishPortuguese, PortugalPortuguese, BrazilRomanianRussianScotsNorthern SamiSinhalaSlovakSlovenianAlbanianSerbianSwedishSwahiliTamilTamil, Sri LankaTeluguThaiTurkishTuvanUyghurUkrainianUrduVietnameseLolspeakChinese, SimplifiedChinese, Traditional Secondary Language (if applicable) - None -AfrikaansAmharicArabicAsturianAzerbaijaniBelarusianBulgarianBengaliTibetanBosnianCatalanCzechWelshDanishGermanDzongkhaGreekEnglishEsperantoSpanishEstonianBasquePersian, FarsiFinnishFilipinoFaeroeseFrenchFrisian, WesternIrishScots GaelicGalicianSwiss GermanGujaratiHebrewHindiCroatianHaitian CreoleHungarianArmenianIndonesianIcelandicItalianJapaneseJavaneseGeorgianKazakhKhmerKannadaKoreanKurdishKyrgyzLaoLithuanianLatvianMalagasyMacedonianMalayalamMongolianMarathiBahasa MalaysiaBurmeseNepaliDutchNorwegian BokmålNorwegian NynorskOccitanPunjabiPolishPortuguese, PortugalPortuguese, BrazilRomanianRussianScotsNorthern SamiSinhalaSlovakSlovenianAlbanianSerbianSwedishSwahiliTamilTamil, Sri LankaTeluguThaiTurkishTuvanUyghurUkrainianUrduVietnameseLolspeakChinese, SimplifiedChinese, Traditional What special skills/abilities/experiences do you bring to the role of SP? Information message Your personal health status and experiences will impact your simulated participant portrayals. Please answer the following questions briefly to help us best match your characteristics to our curriculum needs. List distinguishing physical features such as scars, birthmarks, tattoos and specify where they are located. List current medical conditions List any physical limitations you may have List any surgeries you have had and the year you had them allergies Arthritis Allergies Back Bladder Bleeding Blood Pressure Bowel Breathing Diabetes Ears Eyes Gallbladder Gynecological Heart Hormone Joints Kidneys Liver Lungs Migraine Muscles Neck Pregnancies Prostate Psychological Sinus Skin Stomach Throat Thyroid Ulcer Other None of the above Other problem(s) Why are you interested in being a Simulated Participant? Information message Availability SPs are used primarily in morning or afternoon sessions lasting 2-4 hours. Occasionally, SPs are needed for several consecutive full days. Please indicate your availability to work as an SP. Please indicate what days you would be available. Monday Tuesday Wednesday Thursday Friday Please indicate the time(s) you would be available. Morning Afternoon Full Days Information message Types of SP Experiences The UMMC College of Medicine needs SPs for many types of learning and testing situations. You will not be asked to participate in any type of examination you are not comfortable with. Please indicate which of the following types of educational experiences you would not be willing to participate in. Portrayals that require wearing a hospital gown (underclothes may be worn) Upper body physical examination (student will listen to hearts and lungs with a stethoscope) Lower body physical examination (student will examine, press on abdominal area and listen with a stethoscope) I am willing to participate in all of the above Role Preferences Gay/lesbian/bisexual Transgender Alcohol abuse Drug abuse HIV Positive Victim of physical abuse Victim of sexual abuse Sexually promiscuous/unfaithful to partner Sexual dysfunction (e.g., erectile dysfunction, pain during sexual activity, low sex drive) Perpetrator of abuse Criminal/prisoner/former prisoner Angry/aggressive/mean Mental health condition (e.g., bipolar disorder, schizophrenia, borderline personality disorder, PTSD) Race-related issues Using profanity Overweight Provocative/promiscuous/overly flirtatious End of life Leave this field blank
