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1. Demographic Information

1. Name:

2. Address:

3. Phone:

4. Cell phone:

5. E-mail Address

6. Current degree in nursing:

7. Please indicate the top three areas of interest in pursuing a Master's Degree:

  first choice second choice third choice
Clinical Nurse Leader
Clinical Nurse Specialist
Community Health-Public Health Nursing
Family Nurse Practitioner
Nursing Education

9. If you were to enroll as a student, what type of study would you prefer?

10. What type of learning format would you prefer? Check as many as apply:

11. If a course would have classroom or lab time, what would be the best time for you?

12. If a course had a classroom component, which day of the week would work the best? Check as many as apply.

13. Based on your previous education, which type of educational program track would you be interested in?

14. If you already have a Master's degree in nursing would you be interested in participating in a program that leads to a certificate (i.e, Family Nurse Practitioner, Gerontology, Women's Health, Palliative Care)?