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)?