Thank you for applying to become a Standardized Patient with the University of Victoria School of Nursing's Nurse Practitioner Program. Your personal information is collected under section 26 of the Freedom of Information and Protection of Privacy Act (FIPPA), RSBC 1996, c.165, for the purposes of administering UVic Nurse Practitioner Patient Programs. Information will be shared with UVic program staff only on a need-to-know basis. If you have questions about the collection of this information, please contact Sandy Meadow, NP Program Manager (smeadow@uvic.ca).

Question Title

1. Family name (surname) (Required.)

Question Title

2. LEGAL given name(s) (Required.)

Question Title

3. Preferred name (if different from legal given name)

Question Title

4. Address (including postal code) (Required.)

Question Title

5. Phone (cell) (Required.)

Question Title

6. Phone (other)

Question Title

7. Email address (Required.)

Question Title

8. Date of Birth (Required.)

Date

Question Title

9. Gender (Required.)

Question Title

10. Ethnic, racial, or cultural identity (Required.)

Question Title

11. Occupation (Required.)

Question Title

12. How did you find out about Standardized Patient work with the UVic Nurse Practitioner Program? (Required.)

Question Title

13. What experience, if any, do you have with acting, teaching, coaching, or public speaking? (Required.)

Question Title

14. What interests you about being a Standardized Patient? (Required.)

Question Title

15. What experiences do you have with the healthcare system? Perhaps you have had health issues and have been a patient yourself. Perhaps you have had positive or negative experiences – or a mix of both. Please tell us a little about this if you feel comfortable.

We collect the following information about physical characteristics to help match you with roles as a Standardized Patient.

Question Title

16. Height (Required.)

Question Title

17. Weight (Required.)

Question Title

18. Please describe any noticeable physical findings you have, such as a heart murmur, surgical scars, skin conditions (psoriasis, eczema, etc.), use of hearing aids, or any conditions that could affect you during simulations, such as arthritis, chronic pain, etc. (Required.)

Question Title

19. What aspects of a role (if any) would you NOT feel comfortable portraying? (Examples could include things like discussing sexual history, cases involving abuse, or portraying depression.) (Required.)

Question Title

20. Are you comfortable with a role that involves a physical exam? These may include exams of the arms, legs, belly, or chest, but any examination of the chest would only involve listening to your heart or lungs -- no breast exams. You would always be gowned or dressed; a stethoscope would be placed beneath your gown or shirt. There would always be a supervising Nurse Practitioner in the room along with you and the student. (Required.)

Question Title

21. Please feel free to share anything else you think is important for us to know.

Thank you again for your interest in becoming a Standardized Patient. We'll be in touch with you soon to discuss next steps.

Sandy Meadow
NP Program Manager
smeadow@uvic.ca

T