Duke-NUS Simulated Patient Program Application Form

Personal Information

Salutation

Surname/Family Name

Given Name

Date of Birth

Nationality

Ethnicity/Race

Religion

Contact Details

Postal Address

Contact Numbers

Email Address

Please upload a recent passport sized (400 pixel by 512 pixel) photograph of yourself.

Your Interest in the SP Program:

1. How did you find out about the Duke-NUS Simulated Patient Program? (E.g.: Word of mouth, newspaper article, internet, etc)

2. What makes you interested in becoming a Simulated Patient? (Briefly explain)

3. Some Simulated Patients are needed for physical examinations. Are you comfortable wearing a hospital gown while a student examines you?

Yes

No

4. What special skills do you think you will bring to this job?

5. Do you have any work experience that would be considered similar or applicable to this type of work?

Education Background

Which language(s) can you read?

Proficiency Level

Minimal Level

Fluent

Which language(s) can you speak?

Proficiency Level

Minimal Level

Fluent

Computer literacy

Are you comfortable using a computer and a mouse?

Yes

No

Health Background:

Do you have any illnesses at the moment? (E.g.: Asthma, Diabetes, etc)

Yes

No

If YES, please specify:

Have you had surgery or an accident in the past that left a visible scar?

Yes

No

If you answered YES to the above questions, please specify the type of medical condition you have and/or the location and cause of any scars:

Employment History

Are you currently employed?

Yes

No

If YES, please specify:

Select a choice

Full Time

Part Time

Retired

Self-employed

Student

Please specify the days and the time slots you are available to work for the SP program.

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