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Sunday, May 26, 2024   12:43 PM    |   89°F


First Name:
Middle Name:
Last Name:
Employer Address:
City, State, Zip:     
Cell Phone:
Birth Year:
Gender Identity:
(Select all that apply):

Veteran Status:

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

How many years of teaching experience do you have?

Highest Degree Earned (Choose one)

Nursing Role (Choose one)

Faculty Appointment with a school of nursing?

Currently Precept?

Primary Area of Clinical Practice

Registered Nurse

Nurse Midwife (Select all that apply)

Nurse Practitioner (Choose one and specify as needed)



Zip Code of Primary Clinical Practice Site

Primary Clinical Practice Site Type (Choose one)

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.)

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

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.)

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.])

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

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