EmailMeForm
CSBL SP Booking Form
Standardized Patient Program-McMaster University
Please note: We require a minimum notice of 5 business days for catalogue case requests, excluding the simulation date. Custom cases require a notice of 10 business days excluding the simulation date.
Request ID
Requestor Name
*
First and last name
Requestor Email
*
Phone
*
###
-
###
-
####
ext. or pager number
Institution
*
Program of Learners
*
e.g. Anesthesia, Nursing, etc.
Level of learners
*
e.g. MF2, Year 1, Level 3, N2J04, etc.
If Program of Learners is McMaster School of Nursing (BScN), please identify stream
Please select
McMaster School of Nursing (BScN) - Accelerated Stream
McMaster School of Nursing (BScN) - Basic Stream
McMaster School of Nursing (BScN) - Mohawk Stream
OTHER program - not applicable
McMaster School of Nursing (BScN) please select stream. Other programs select not applicable.
Name of Person who is to be invoiced:
*
Type of session:
*
Please select
In person
Virtual
Please indicate in-person or virtal.
Booking Location:
*
Location
McMaster - Hamilton Campus
Niagara College
McMaster - Niagara Regional Campus
McMaster - Waterloo Regional Campus
Brock University
Other (ensure details are provided under "Location Details")
Is this session being recorded?
*
Yes
No
Please provide specifics of how this recording will be utilized.
*
VIRTUAL SESSION INFORMATION
For VIRTUAL sessions, please specify the platform:
Please select
Zoom
Webex
Google Meet
Other
Please provide VIRTUAL session / meeting link (if applicable)
SESSION INFORMATION
Facilitator
*
Facilitator Email
*
Session Title
*
Group Number
eg. UGME Clinical Skills Group 1
Session Date
*
MM
/
DD
/
YYYY
SP Start Time
*
HH
:
MM
AM
PM
AM/PM
SP End Time
HH
:
MM
AM
PM
AM/PM
Number of Standardized Patients PER CASE
*
e.g. If you require 1 SP for case #1094 and 1 SP for case #1457, please enter 1
Attachment(s):
Add File
Attach large SP request spreadsheet and/or custom cases here
Case Numbers
Please enter numbers from Catalogue
Is this a custom case:
*
Please select
yes
no
Are you requesting a physical exam with NO history (case 1094)?
*
Please select
yes
no
If yes: Physical Exam: Gender (case #1094 only)
Male
Female
No preference
If yes: Physical Exam: Age (case #1094 only)
Young(18-39)
Middle Aged (40-59)
Senior (60+)
No preference
If yes: Physical Exam: Body Type (case #1094 only)
Underweight
Average weight
Overweight
No preference
State what type of exam the SP will be involved in:
*
Will the SP be required to provide feedback to the learners?
*
Yes
No
Uncertain
Our SP's are trained to provide feedback from the patient perspective only, and will not address any clinical content.
If you would like to provide further details around feedback requirements, please do so here.
Break Information
Please select
One 30-minute break (unpaid to SP, not invoiced back to requesting program)
Two 15-minute breaks (paid to SP, invoiced to requesting program)
Not applicable
Please indicate the type of break which will be provided to the SP.
If the SP is being requested for 5 hours or more, breaks free from work must
be provided in accordance with the Employment Standards Act
https://www.ontario.ca/document/your-guide-employment-standards-act-0/hours-work#section-3
Break start/end time(s)
Additional Breaks
LOCATION DETAILS
Please indicate the location for SP. Please provide all the following information:
1. Complete address / room location
2. Emergency contact number
3. Where the SP will be meeting you. (E.g. main foyer)
*
Email
