All MSN applicants are encouraged to complete this survey at time of program application; information provided on this survey will be kept confidential.
Anticipated program admission - semester Fall Spring Summer year 2007 2008 2009 2010 Anticipated program progression Full-time (9+ credit hours) Part-time (3-6 credit hours)
Laker ID (i.e. 900xxxxxx) Title Ms. Mr. Name - First Middle Last
Current Address City State Zip
Name and location of current employer (e.g. Henry Medical Center, Stockbridge, GA)
Length of employment 0-2 years 3-5 years 6-10 years 11-15 years 16-20 years Over 20 years Certification in national nursing specialties
Indicate if you are interested in working in a health professional shortage area (http://www.bphc.hrsa.gov/databases/newhpsa/newhpsa.cfm) or areas with a federal designation of a medically underserved area. The list of practice sites found within these areas include (check all that apply):
community health centers
migrant health centers
health care for the homeless grantees
public housing primary care grantees
federally designated rural health clinics
National Health Service Corps sites
Indian health services
federally qualified health centers
state health departments or local health departments that are funded by State
ambulatory practice sites designated by state governors as serving medically underserved communities
Identify which of the following specialty focus areas you are interested in pursuing advanced education (check all that apply):
acute care
genetics
oncology
adult
home health
palliative
adolescent
immunosuppressive nursing
pediatrics
case management
informatics
perinatal
chronic/long-term
maternal-child/parent-child
primary care
community health
medical-surgical
psychiatric/mental
critical care
neonatal
public health
environmental
nurse administration
public policy
family
nurse anesthesia
rehabilitation
forensics
OB-GYN/women's health
research
geriatric/gerontology
occupational
school health
other
To identify potential financial and support needs among our students, indicate if any of the following statements apply to you:
person from a high school where SAT scores or state test results were below average
person from a high school where at least 30% of enrolled students were eligible for free or reduced price lunches
person from a school district where 50% or less of graduates go to college
person who is first generation to attend college and who is from a rural or urban area or receiving public assistance
person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences
person for whom English is not their primary language and for whom language is still a barrier to their academic performance
Other comments or questions.