Simulated Participants Form | Carolinas Simulation Center

Please complete this application to help us determine if we can incorporate you into our educational activities. This information will be kept confidential and on file for current and future activities. Please keep in mind that all activities are short term and temporary. We will be in contact to discuss the program. You must be 18 years or older to apply.

If you have any additional questions, please see our FAQs for SPs, or contact our Simulated Participant Coordinator, Leslie Nester at Leslie.Nester@atriumhealth.org.

Full Name Address

Our sessions primarily take place at the flagship hospital of Atrium Health in Charlotte, NC. Do you live within an hour of this location? Yes No

Phone Number Email Address Occupation (or former if unemployed): (We do not need to contact your employer, this is only for informational purposes) Date of Birth Languages Spoken (Other than English) How did you hear about us? Why are you interested in working as a simulated participant?

Our learners may conduct a focused physical exam on you. You may be required to dress in a hospital gown wearing only undergarments. Learners are not allowed to do a pelvic, rectal, or genital exam. Are you comfortable with this? Yes No

Please list any scars, tattoos, and/or birthmarks (if any) Have you had any chronic medical conditions or past surgeries (this will help us match specific cases to our simulated participants)? If yes, please specify below What special skills or abilities do you feel you would bring to this role (i.e., clinical, acting, teaching skills)? Do you have any prior experience with health care simulation (including time as a learner)? Briefly describe your feelings about and experiences with physicians and other health care providers. Carolinas Simulation Center is open Monday through Friday from 8 a.m. to 5 p.m., and any sessions that take place off site usually fall in that same time frame with a few exceptions. What's your availability during these hours? (days, hours, times of year) Upload a picture of yourself

If you are an Atrium Health employee, please complete the rest of the form. If not, please scroll to the submit button below.

Department Name Job Title Department Manager Department Phone Employee ID#

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