GNE Survey Submission * 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? Male Female * 16. Date of birth: [MM/DD/YYYY] * 17. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino * 18. What is your race? Mark one or more. White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other * 19. Language Skills: Arabic Chinese Mandarin Signing for the Hearing Impaired Portuguese English Farsi Hindi Spanish Vietnamese Filipino Tagalog Italian French Chinese Cantonese Japanese Korean Russian German Other (please specify) * 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: Fall Spring Summer * 24. Nursing school currently enrolled in: * 25. Student ID#: * 26. Expected graduation: Fall 2015 Spring 2016 Summer 2016 Other (please specify) * 27. Currently employed: Yes No * 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: Associate Degree RN or Diploma RN BA BSN MBA MS PhD Other (please specify) * 39. Specialty pursued: * 40. Program type: * 41. Current Credentials, Licenses and/or Certifications: * 42. Type of placement preferred: Clinic Family Medicine Hospice Hospital LTAC Rehab SNF Surgical Center Other (please specify) * 43. Brief biography including experience and future aspirations: Done