Basic Information 

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* 1. Name:

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* 2. Credentials:  (please include degree, licensure, and certifications)

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* 3. Organization:

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* 4. Primary Email:

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* 5. Secondary Email

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* 6. Role:
(please list your title and a brief description of your area(s) of responsibility, span of control, etc...)

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* 7. Time in current role:

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* 8. What do you hope to gain in this program?
(please be specific about your personal learning goals or needs)

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* 9. Where do you currently feel stuck with your skills as a nurse leader?  
(i.e. what are your day to day "pain points" when leading your team?)

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* 10. Please review the program components listed on the website, then rank the importance to you of each of the four components listed below, with 1 being the most important for you to learn and develop skills, and 4 being the least important to your learning/development.

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