UAMS.EDU

Standardized Patient Application

If you are a current UAMS employee, unfortunately we can not use your services as a standardized patient.

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.
  • Please select one of the following
  • I, the undersigned, a standardized patient, standardized participant, teaching associate, or exam model, for the University of Arkansas, operated by the Board of Trustees of the University of Arkansas, hereby voluntarily agree to give my express consent to: 1. Authorize the professional staff and such assistants, photographers, and technicians to take still photographs and motion pictures and produce educational (closed circuit) television programs, including video tapes, as well as other visual and/or auditory/digital recordings. 2. Permit such photographs, motion pictures, video tapes and/or auditory/digital recordings to be published and republished in professional journals and medical books to be used for any other purpose which the staff member may deem fit in the interest of medical education or research and to be used as professional meetings of any kind. 3. Further authorize the modification or retouching of such photographs and the publication of information relating to my case, either separately or I connection with the publication of the photographs taken of me. In addition the above, I also agree to the following: 4. Although I have given permission to the publication of all details and photographs concerning my case, it is understood that I will not be identified by name. 5. I understand that all information regarding the standardized patient case for which I have been trained is the confidential property of UAMS, and I agree that I will not disclose to any third party any information about the standardized patient case or information about the students who I have seen during the examination. 6. I understand that all rights of every kind and nature (including copyrights) in and to all photographs, motion pictures, video tapes and/or auditory digital recordings made in connection with this standardized patient case by UAMS shall be and remain vested on UAMS for purposes in perpetuity.
  • This field is for validation purposes and should be left unchanged.

If you’d prefer to mail, email, fax or physically bring us your application, you may print the form and return to us at your convenience.

SP data form – UAMS 2013