RN/Intern Demographics:
This form provides registration into the Internship Project and establishes a database for outcomes analysis related to the Internship Project. All information that is collected via this form, other Internship documents, and/or exit interview will be held in strict confidentiality. It will be shared only in statistical format - without identifying data. As part of Internship Project data collection and outcomes tracking, the information you include below might be used to contact you at least annually for 2 to 3 years post Internship. If you work for less than 2 years at the Internship facility, an exit interview is required for the sake of recruitment/retention tracking. If an exit interview is not completed with your hiring facility, please contact the project director at daystarfarm@earthlink.net or sboyer@vnip.org or phone 802-674-7069.

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* Please complete the following:

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* Please complete the following

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* Gender

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* Age Range

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* Race/Ethnicity - Please select the answer that best describes your situation.

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* Please complete the following:

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* Type of Intern

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* How long do you plan to stay in this position?

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* Do you have prior work experience of any type?

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* If yes, how many years?

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* Please describe the type of work you previously did.

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