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* 1. First name:

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* 2. Middle Initial:

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* 3. Last name:

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* 4. Street Address:

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* 5. Apt. Number:

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* 6. City

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* 7. State:

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* 8. Zip code:

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* 9. Personal email address:

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* 10. School email address:

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

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* 12. Home number:

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* 13. Cell phone number:

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* 14. Other number:

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* 15. Are you male or female?

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

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

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

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* 20. Date of initial enrollment:

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

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* 22. Academic year at time of survey:

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* 24. Nursing school currently enrolled in:

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* 25. Student ID#:

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* 27. Currently employed:

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* 28. Place of current employment:

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* 29. Employer address:

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* 30. City:

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* 31. State:

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* 32. Zip code:

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

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* 34. Complete street address:

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* 35. City:

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* 36. State:

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* 37. Zip code:

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* 38. Degree received:

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* 39. Specialty pursued:

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* 40. Program type:

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

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* 42. Type of placement preferred:

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* 43. Brief biography including experience and future aspirations:

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