GNE Survey Submission First name: Question Title * 1. First name: Middle Initial: Question Title * 2. Middle Initial: Last name: Question Title * 3. Last name: Street Address: Question Title * 4. Street Address: Apt. Number: Question Title * 5. Apt. Number: City Question Title * 6. City State: Question Title * 7. State: Zip code: Question Title * 8. Zip code: Personal email address: Question Title * 9. Personal email address: School email address: Question Title * 10. School email address: Work email address: (please put personal email if no work email address) Question Title * 11. Work email address: (please put personal email if no work email address) Home number: Question Title * 12. Home number: Cell phone number: Question Title * 13. Cell phone number: Other number: Question Title * 14. Other number: Are you male or female? Question Title * 15. Are you male or female? Male Female Date of birth: [MM/DD/YYYY] Question Title * 16. Date of birth: [MM/DD/YYYY] Are you of Hispanic or Latino origin or descent? Question Title * 17. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino What is your race? Mark one or more. Question Title * 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 Language Skills: Question Title * 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) Date of initial enrollment: Question Title * 20. Date of initial enrollment: Type of enrollment: MSN or BSN? If other, please specify. Question Title * 21. Type of enrollment: MSN or BSN? If other, please specify. Academic year at time of survey: Question Title * 22. Academic year at time of survey: Academic period: Question Title * 23. Academic period: Fall Spring Summer Nursing school currently enrolled in: Question Title * 24. Nursing school currently enrolled in: Student ID#: Question Title * 25. Student ID#: Expected graduation: Question Title * 26. Expected graduation: Fall 2015 Spring 2016 Summer 2016 Other (please specify) Currently employed: Question Title * 27. Currently employed: Yes No Place of current employment: Question Title * 28. Place of current employment: Employer address: Question Title * 29. Employer address: City: Question Title * 30. City: State: Question Title * 31. State: Zip code: Question Title * 32. Zip code: Prior place of employment: ('NA' if not applicable) Question Title * 33. Prior place of employment: ('NA' if not applicable) Complete street address: Question Title * 34. Complete street address: City: Question Title * 35. City: State: Question Title * 36. State: Zip code: Question Title * 37. Zip code: Degree received: Question Title * 38. Degree received: Associate Degree RN or Diploma RN BA BSN MBA MS PhD Other (please specify) Specialty pursued: Question Title * 39. Specialty pursued: Program type: Question Title * 40. Program type: Current Credentials, Licenses and/or Certifications: Question Title * 41. Current Credentials, Licenses and/or Certifications: Type of placement preferred: Question Title * 42. Type of placement preferred: Clinic Family Medicine Hospice Hospital LTAC Rehab SNF Surgical Center Other (please specify) Brief biography including experience and future aspirations: Question Title * 43. Brief biography including experience and future aspirations: Done
