Application

First Name:	First Name is required.
Middle Name:
Last Name:	Last Name is required.
Credentials:	Credentials is required.
Position/Title:	Position/Specialty is required.
Employer:	Employer is required.
Employer Address:	Employer address is required.
City, State, Zip:	Employer city is required.   Employer state is required.   Employer zip is required.
Cell Phone:	Cell Phone is required.
Email:	Email is required.
Birth Year:	-- 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000  Birth Year is required.
Gender Identity:	-- Female Male Transgender or non-binary or another gender  Gender Identity is required.
Ethnicity:	-- Hispanic/Latino Non-Hispanic/Non-Latino  Ethnicity is required.
Race (Select all that apply):	American Indian/Alaskan Native Black or African American White Asian Native Hawaiian or Other Pacific Islander
Veteran Status:	-- Active Duty Military National Guard Veteran � Prior Service Not a Veteran Reservist Veteran - Retired  Veteran Status is required.

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What teaching experience did you have before this training (select all that apply)?

None
Simulation teaching
Clinical faculty
Precepting

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How many years of teaching experience do you have?

-- 0 1 month to 9 months 1 year to 2 years 2 years to 5 years More than 5 years  Years Teaching is required.

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Highest Degree Earned (Choose one)

-- AA/AS BSN MSN MN DNP PhD Other  Hightest Degree is required.

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Nursing Role (Choose one)

RN
APRN

Nurse Practitioner

Acute Care or Adult Gerontology Acute Care
Adult or Adult Gerontology Primary Care
Family
Neonatal
Pediatric Acute Care
Pediatric Primary Care
Psychiatric Mental Health (across the lifespan)
Women's (Gender related) Health

Nurse Midwife

CNS

CRNA

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Faculty Appointment with a school of nursing?

-- Yes No  Faculty Appointment is required.

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Currently Precept?

-- Yes No  Currently Precept is required.

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Primary Area of Clinical Practice

Registered Nurse

Hospital
Primary Care Clinic
Specialty Care Clinic

Nurse Midwife (Select all that apply)

Peripartum
Labor and Deliver
Primary and Reproductive Health Care
General Reproductive Health Care

Nurse Practitioner (Choose one and specify as needed)

Primary Care
Specialty Care (e.g. Cardiology, Pulmonology, Infectious Diseases, Gastroenterology, Nephrology, etc.)

Specify

Inpatient Service (e.g. Critical Care, Surgery, Trauma, Internal Medicine, etc.)

Specify

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Zip Code of Primary Clinical Practice Site

 This field is required.

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Primary Clinical Practice Site Type (Choose one)

-- Community health center Community-based organization FQHC or look-alike Nurse managed health clinic Independent living facility Mobile clinic Nursing home Long-term care facility Other oral health facility Residential living facility Mental health practice/rehabilitation/substance abuse clinic Acute care for the elderly (ACE) units Community mental health center Day and home care programs (e.g. home health) Emergency room Federal and state bureau of prisons Hospice Indian Health Service (IHS) site Local health department State health department National health association Federal government office or agency International nonprofit/nongovernmental organization Physician office School-based clinic Tribal health department Tribal organization Hospital Acute care services Critical access hospital Dentist office Extended care facility Community care program for elderly or mentally challenged individuals Other community health center (e.g. free clinic) Program of all-inclusive care for the elderly Senior center  This field is required.

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Clinical Practice Site serves a Medically Underserved Community?
(HRSA definition: A geographic location or population of people eligible for designation by the federal government as a health professional shortage area, medically underserved area, medically underserved population, or governor's certified shortage area for rural health clinic. As an umbrella term, MUC also includes populations such as people experiencing homelessness, migrant or seasonal workers, and residents of public housing. Click here to find shortage areas by address.)

-- Yes No  This field is required.

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Select which population(s) you care for on a daily basis. (Select all that apply)

Children
Adolescents
College students
Refugee adults
Older adults
Undocumented immigrants
Pregnant women and infants
People living with disabilities
Tribal population(s)
Military and/or military families
Veterans
Returning war veterans
Victims of interpersonal violence, abuse, or other trauma
Individuals experiencing homelessness
Individuals with chronic illness
Lesbian/gay/bisexual/transgender
Uninsured/underinsured individuals or families
Low income
Unemployed
None of the above

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Do you live in a rural residential area?
(HRSA Definition: A geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as rural. Use the Rural Health Grants Eligibility Analyzer (click here) to determine whether the Federal Office of Rural Health Policy considers a geographical area rural.)

-- Yes No  This field is required.

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Personal Disadvantaged Background
(HRSA definition: Someone who is any/all of these: Environmentally Disadvantaged [A person's environment inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school.]; Economically Disadvantaged [A person from a family with an annual income below a level based on low-income thresholds, according to family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of the U.S. Department of Health and Human Services, for use in all health professions programs. A family is a group of two or more people. The Secretary updates these income levels in the Federal Register annually.]; Educationally Disadvantaged [A person who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the person from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program. This person must also be a citizen, national, or a lawful permanent resident of the United States, Commonwealths of Puerto Rico, Marianas Islands, U.S. Virgin Islands, Guam, American Samoa, Trust Territory of the Pacific Islands, Republic of Palau, Republic of the Marshall Islands, Federated State of Micronesia.])

-- Yes No  This field is required.

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Are you interested in the National League for Nursing Clinical Nurse Educator-clinical certification upon completion of this program?

-- Yes No  This field is required.

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In what capacity of a clinical nurse educator are you interested in serving as upon completion of this program?

-- Clinical faculty with a school of nursing Clinical preceptor with a health care agency Both clinical faculty and preceptor I am not sure yet  This field is required.

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