* 1. First name:

* 2. Middle Initial:

* 3. Last name:

* 4. Street Address:

* 5. Apt. Number:

* 6. City

* 7. State:

* 8. Zip code:

* 9. Personal email address:

* 10. School email address:

* 11. Work email address: (please put personal email if no work email address)

* 12. Home number:

* 13. Cell phone number:

* 14. Other number:

* 15. Are you male or female?

* 16. Date of birth: [MM/DD/YYYY]

* 17. Are you of Hispanic or Latino origin or descent?

* 18. What is your race? Mark one or more.

* 19. Language Skills:

* 20. Date of initial enrollment:

* 21. Type of enrollment: MSN or BSN?  If other, please specify.

* 22. Academic year at time of survey:

* 23. Academic period:

* 24. Nursing school currently enrolled in:

* 25. Student ID#:

* 26. Expected graduation:

* 27. Currently employed:

* 28. Place of current employment:

* 29. Employer address:

* 30. City:

* 31. State:

* 32. Zip code:

* 33. Prior place of employment: ('NA' if not applicable)

* 34. Complete street address:

* 35. City:

* 36. State:

* 37. Zip code:

* 38. Degree received:

* 39. Specialty pursued:

* 40. Program type:

* 41. Current Credentials, Licenses and/or Certifications:

* 42. Type of placement preferred:

* 43. Brief biography including experience and future aspirations:

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