Standardized Patient (SP) Request Form

Please provide your contact info:

Title: *

Name: *

Department: *

University email: *

Campus phone: *

Campus address: *

Please provide dates for your event (please provide multiple options as other simulation events may be scheduled): *

What is the level of participants using the simulation space? (Select all that apply):

If other level of participant, please describe:

Type of Event:

If other type of event, please describe:

Location: *

Simulation Center

Clinical Performance Center (BSLC)

Clinical Area

Details:

Number of SP's? *

Please specify if you require specific gender, age, ethnicity, or body type. *

Please note that while we do not have an unlimited number of SP's, we will do our best to meet your request.

Do you need assistance with case development? *

Yes

No

Do you require the use of B-Line? (Digital recording and data storage software) *

Yes

No

Finance:

The hourly rate for SP's ranges from $18.00 to $22.00 per hour, depending on the event.

*

Check

Departmental Account

Please make check payable to The University of Chicago Medical Center Mail to: The University of Chicago Simulation Center 5841 S. Maryland Ave. Suite 119, MC 5030 Chicago, Il 60637

Name of Department responsible for compensating SPs (as listed on account): *

Cost Center: *

6 digit departmental fund code

Name of signatory: *

Administrative person responsible for and authorized to make purchases.

Standardized Patient Usage Agreement

When standardized patients are used, temporary employee guidelines apply. If for some reason you must cancel an event date, at least 3 weeks notice must be given to SP’s. If less than 3 weeks notice is given, SP’s must be paid a 4 hour minimum for that work date. For trainings canceled with less than 2 weeks notice, SP’s must be paid a 2 hour minimum for that training date.

*

I agree with these terms.

Standardized Patient (SP) Request Form

Details:

Finance:

Standardized Patient Usage Agreement

Share this: