Simulated Participant Interest Form First Name Last Name Date of Birth Occupation Employer (if any) Gender - Select - Man Woman Non-binary Agender/Genderless Androgyne/Androgynous Aporagender Bigender Demi-agender Demi-boy Demi-fluid Demi-girl Demi-gender Demi-non-binary Genderqueer Genderflux Genderfluid Gender-indifferent Gender-neutral Graygender Intergender Maverique Maxigender Multigender/Polygender Neutrois Pangender/Omnigender Trigender Two-spirit Prefer Not to Answer Height Weight Ethnic Background Other Causasian Asian African American / Black Hispanic Mediterranean Other other_ethnicity Address Address Address 2 City/Town State/Province - Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon 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 - Afrikaans Amharic Arabic Asturian Azerbaijani Belarusian Bulgarian Bengali Tibetan Breton Bosnian Catalan Czech Welsh Danish German Dzongkha Greek English English, British Esperanto Spanish Estonian Basque Persian, Farsi Finnish Filipino Faeroese French Frisian, Western Irish Scots Gaelic Galician Swiss German Gujarati Hawaiian Hebrew Hindi Croatian Haitian Creole Hungarian Armenian Indonesian Icelandic Italian Japanese Javanese Georgian Kazakh Khmer Kannada Korean Kurdish Kyrgyz Lao Lithuanian Latvian Malagasy Macedonian Malayalam Mongolian Marathi Bahasa Malaysia Maltese Burmese Nepali Dutch Norwegian Bokmål Norwegian Nynorsk Occitan Odia Ossetian Punjabi Polish Persian, Afghanistan Pashto Portuguese, International Portuguese, Portugal Portuguese, Brazil Rohingya Rumantsch Grischun Romanian Russian Kinyarwanda Scots Northern Sami Sinhala Slovak Slovenian Albanian Serbian Swedish Swahili Tamil Tamil, Sri Lanka Telugu Thai Turkish Tuvan Uyghur Ukrainian Urdu Vietnamese Lolspeak Chinese, Simplified Chinese, Traditional Secondary Language (if applicable) - None - Afrikaans Amharic Arabic Asturian Azerbaijani Belarusian Bulgarian Bengali Tibetan Breton Bosnian Catalan Czech Welsh Danish German Dzongkha Greek English English, British Esperanto Spanish Estonian Basque Persian, Farsi Finnish Filipino Faeroese French Frisian, Western Irish Scots Gaelic Galician Swiss German Gujarati Hawaiian Hebrew Hindi Croatian Haitian Creole Hungarian Armenian Indonesian Icelandic Italian Japanese Javanese Georgian Kazakh Khmer Kannada Korean Kurdish Kyrgyz Lao Lithuanian Latvian Malagasy Macedonian Malayalam Mongolian Marathi Bahasa Malaysia Maltese Burmese Nepali Dutch Norwegian Bokmål Norwegian Nynorsk Occitan Odia Ossetian Punjabi Polish Persian, Afghanistan Pashto Portuguese, International Portuguese, Portugal Portuguese, Brazil Rohingya Rumantsch Grischun Romanian Russian Kinyarwanda Scots Northern Sami Sinhala Slovak Slovenian Albanian Serbian Swedish Swahili Tamil Tamil, Sri Lanka Telugu Thai Turkish Tuvan Uyghur Ukrainian Urdu Vietnamese Lolspeak Chinese, Simplified Chinese, 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
