1. Thank you for your interest the 2012 Summary PNA Program!

Please complete the following survey.

* 1. Please complete the following demographic information.

* 2. Please indicated which nursing program you are currently enrolled in.

* 3. Please indicate the name of your school of nursing.

* 4. Please indicate the anticipated year of your graduation

* 5. Please indicate the facility(ies) and type of unit(s) you've completed any clinical rotations.

* 6. Are you currently a Duke employee?

* 7. Can you work a 36-40 hour day/night rotation schedule for the entire 10 week program? (Program runs June 4th-August 12th)

* 8. Please indicate if you are currently certified Nursing Care Assistant I or II. (Note- this is not required to apply. However, you will need to obtain NC NA I or NA II registry by May 18, 2012 in order to participate in the program)

* 9. Please indicate preferred facility. Please know that we can not guarantee your preferred facility.

* 10. Please indicate up to 3 unit preferences. Please know that we can not guarantee preferred units.

* 11. Please respond to the following behavioral interview questions based on Duke values:

Excellence: We strive to achieve excellence in all that we do.

Give two examples of things you've done in previous jobs or in school that demonstrate excellence as an employee or student.

* 12. Safety: We hold each other accountable to constantly improve culture that ensures the
safety and welfare of all patients, visitors.

Tell of a time when you felt uncomfortable (or unsure) in completing an assignment or task. What did you do?

* 13. Integrity: Our decisions, actions, and behaviors are based on honesty, trust, fairness, and the highest ethical standards.

Describe a specific time when you had to handle a tough problem which challenged fairness or ethical issues.

* 14. Diversity: We embrace differences among people.

What measures have you taken to make someone feel comfortable in an environment that was obviously uncomfortable with his or her presence?

* 15. Teamwork: We have to depend on each other and work well together with mutual respect to achieve common goals.

Tell us about the most effective contribution you have made as part of a task group or special project team.