Standardized Patient and Patient Instructor Application

If you live in the Charlottesville area and are interested in being a Standardized Patient or Patient Instructor, fill in the application below. When you have completed the application, click the "Submit" button. You can also print this form and mail to the address below.

Applications are reviewed periodically. Employment with CSTAP is part-time and temporary. The number of participants is variable and dependent upon the specific needs of the program.  If you have any additional questions, please contact Anne Chapin, Coordinator at (434) 243-9477 or achapin@virginia.edu .

Thank you very much for your interest!

CSTAP
The University of Virginia School of Medicine
P.O. Box 800382
Charlottesville, Virginia 22908

  1. First and Last Name:
  2. Address: (include city, state, and zip code)
  3. Phone Number(s):
    (please indicate if you have a message phone with answering machine *)
  4. E-mail address:
  5. Employer/Occupation:
  6. Work Phone:
  7. Date of Birth:
  8. Foreign Languages Spoken:   
  9. What days/times/seasons are you available for work:
  10. Why are you interested in working as a Standardized Patient or Patient Instructor?
  11. What special skills or abilities do you feel you would bring to this role?:
  12. Briefly describe your feelings about, and experiences with, physicians and other health care providers:
     
  13. Have you even been a standardized patient before?  If yes, in what program/university did you particiapte?
  14. How did you find out about us?
  15. What questions do you have about being a Standardized Patient?

ALL RESPONSES ARE CONFIDENTIAL


NOTE: If your application was sent successfully, you will receive confirmation. If you do not receive this confirmation, it is possible that an error occurred during transmission. Please resubmit your application. If you continue to have problems, contact us.