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