Professional email address
* must provide value
Please enter your legal first name
* must provide value
Please enter your legal middle name (enter "N/A" if not applicable)
* must provide value
Please enter your legal last name
* must provide value
Cellphone number
* must provide value
Sex assigned at birth
* must provide value
Female
Male
What is your gender identity*?
*Gender identity = is the internal sense of gender. For example, an individual may be male, female, a combination of male and female, or another gender that may not be congruent with a patient's sex assigned at birth.
* must provide value
Please select year of birth from dropdown menu below:
* must provide value
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 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Ethnicity
* must provide value
Hispanic/Latino
Non-Hispanic/Non-Latino
I prefer not to respond
The option "
Race (check all that apply)
* must provide value
Please select your highest degree*:
* must provide value
AA/AS (Associate of Arts / Associate of Science) BS (Bachelor of Science) BS/BSN BSN (Bachelor of Science in Nursing) MSN (Master of Science in Nursing) MHS (Master of Health Science) MMSc (Master of Medical Sciences) MPAS (Master of Physician Assistant Studies) Master's Degree (not otherwise specified) DNP (Doctor of Nursing Practice) PhD (Doctor of Philosophy) DO (Doctor of Osteopathic Medicine) MD (Medical Doctor) DMD (Doctor of Dental Medicine) DDS (Doctor of Dental Surgery) PharmD (Doctor of Pharmacy) PsyD (Doctor of Psychology) Doctoral Degree (not otherwise specified) N/A (inclusive of LPN or RN diploma)
* = You should select your highest degree even if it's not related to nursing
Do you reside in a rural area*?
* Rural area = "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." You may verify if the rural status of your residential location by accessing HRSA's Rural Health Grants Eligibility Analyzer.
* must provide value
Yes
No
Do you consider yourself as someone who have come from a disadvantaged background*?
* Disadvantaged Background = Someone who is environmentally, economically, and/or educationally disadvantaged. For a full definition, please see HRSA's glossary .
* must provide value
Yes
No
Please indicate your current veteran* status:
* Veteran = "Any person who served in one of the seven uniformed services of the United States." For a full definition, please see HRSA's glossary .
* must provide value
I am not a Veteran
Active Duty Military
National Guard
Reservist
Veteran - Prior Service
Veteran - Retired
I do not wish to respond
What is your primary nursing specialty?
* must provide value
Advanced Practice Registered Nurse (APRN) Aggregate/Systems/Organizational Alternative/Complementary Clinical Nurse Leader (CNL) Clinical Nurse Specialist (CNS) Community Health Nursing Forensics Licensed Practical/Vocational Nurse (LPN/LVN) Nurse Administrator Nurse Educator Certified Nurse Midwife (CNM) Nurse Practitioner (NP) Nursing Informatics Public Health Nurse Registered Nurse (RN) Researcher/Scientist Non-Nursing Specialty Other
Please specify your specialty:
Please specify your nursing specialty:
Please further indicate your primary nursing specialty:
* must provide value
Adult Acute Care Adult Gerontology Adult Gerontology Acute Care Pediatric Family Adult Psychiatric/Mental Health Pediatrics Women's Health Child/Adolescent Psychiatric/Mental Health Emergency Care Family Psychiatric/Mental Health Generalist Geropsychiatric Medical Ethics Neonatal Palliative Care Women's Health/Pediatrics Other
Are you employed OR reside within HRSA Region #3? (i.e., Pennsylvania, Delaware, Maryland, Virginia, West Virginia, District of Columbia)
* must provide value
Yes
No
Select YES if Geisinger, Thomas Jefferson, Nemours, or PHMC/NNCC/PA-NWC is your employer
It looks like you've entered a Geisinger email address and are employed by Geisinger. Geisinger is within HRSA Region #3. Please select YES to this question.
It looks like you've entered a Jefferson email address and are employed by Thomas Jefferson. Thomas Jefferson is within HRSA Region #3. Please select YES to this question.
It looks like you've entered a Nemours email address and are employed by Nemours. Nemours is within HRSA Region #3. Please select YES to this question.
It looks like you've entered a PHMC/NNCC/PA-NWC email address and are employed by PHMC/NNCC/PA-NWC. PHMC/NNCC/PA-NWC is within HRSA Region #3. Please select YES to this question.
What is your current employment status?
* must provide value
Full-time
Part-time
Both Full-time and Part-time
On leave of absence
Is Geisinger your primary employer?
* must provide value
Yes
No
Who is your primary employer?
* must provide value
Thomas Jefferson
Nemours
PHMC/NNCC/PA-NWC
Other
You indicated your primary employer is "Other". Please provide the name of your employer:
* must provide value
Please enter your manager's first and last name
* must provide value
Please enter your manager's email address
* must provide value
How would you describe your primary practice site/location?
* must provide value
Inpatient
Outpatient
Long-term care
Public health / community health
Other (please explain)
practice_type_other
* must provide value
Are you primarily employed in a primary care setting?
* must provide value
Yes
No
Are you primarily employed in a medically underserved community*?
* Medically underserved community = "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." For a full definition, please see HRSA's glossary.
* must provide value
Yes
No
Is your primary work/employement location situated in a rural area*?
* Rural area = "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." You may verify if the rural status of your residential location by accessing HRSA's Rural Health Grants Eligibility Analyzer
* must provide value
Yes
No
Please identify your type of employment by clicking on the drop-down menu and selecting the best option among those listed below:
* must provide value
Academic Institution Academic Medical Center Area Health Education Center Certified Community Behavioral Health Center (CCBHC) Community Behavioral Health/Mental Health Center Community Health Center (CHC) Critical Access Hospital Federal Government FQHC or Look-Alike Health Department (local/state/tribal) Hospital (non-academic) Indian Health Service (IHS)/Tribal/Urban Indian Health Center Nursing Home Other Clinical Health Setting Other Community-Based Organization Other Long-term Care Facility Other Specialty Clinic Private Industry Private Practice Residential Living Facility (including independent and assisted living) Rural Health Clinic School-based Clinic State or Local Government US Armed Forces Veterans Affairs Healthcare (e.g. VA hospital or clinic) Pursuing Additional Education or Training Not Currently Employed N/A
The option "
Please enter the city for your primary practice /employment site:
* must provide value
Please select the state for your primary practice/employment site?
* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Minor Outlying Islands Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Please enter the 5-digit zip code of your primary employment site
* must provide value
How long have you worked as a nurse? (in years)
* must provide value
Please enter "0" if less than 1 year.
How long have you worked as a direct patient care nurse (aka, bedside/frontline nurse)? (in years)
* must provide value
Please enter "0" if less than 1 year.
Have you previously worked as a nursing clinical instructor/faculty *?
* = clinical faculty works with a cohort of students from schools of nursing
* must provide value
Yes
No
How long have you worked as a nursing clinical instructor/faculty? (in years)
* must provide value
Please enter "0" if less than 1 year.
Have you previously taken on the role as a nursing preceptor*?
* = Preceptor is a frontline nurse taking on a one to one assignment with student
* must provide value
Yes
No
How long have you taken on the role of a nursing preceptor? (years)
* must provide value
How long have you worked as a nursing CF? (in years) Field annotation: Please enter "0" if less than 1 year.
Are you currently working as a clinical faculty/instructor?
* must provide value
Yes
No
Are you currently serving as a preceptor?
* must provide value
Yes
No
What is your primary shift for teaching clinical?
* must provide value
Day
Evening
Mixed
How many students are within your clinical cohort?
* must provide value
1-4
5-7
8-10
What type of program are your student(s) attending? (Choose all that apply)
* must provide value
At what level are your nursing students? (Choose all that apply)
* must provide value
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