Title Ms. Mr. Name - First Middle Last
Last name while enrolled at Clayton State
Current Address City State Zip
Gender Female Male Race/Ethniticity Asian/Pacific Islander Black (Non-Hispanic Origin) Hispanic Multi-racial Native American/Alaskan Native White (Non-Hispanic Origin) Marital Status Single Married Divorced Widowed Age 18-29 30-39 40-49 50-59 Over 60
Number of Children None 1 2 3 4 5 6 or more If English is a second language (ESL) what is your first language
Citizen, national, or a lawful permanent resident of United States District of Columbia Commonwealths of Puerto Rico Marianas Islands Virgin Islands Guam American Samoa Trust Territory of the Pacific Islands Republic of Palau Republic of the Marshall Islands Federated State of Micronesia Country of Birth
Graduated with ASN BSN (Basic Licensure Track) BSN (RN Completion Track) MSN (Education Track) MSN (Leadership Track) Semester of program graduation Fall Spring Summer Year of program graduation 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973
Current employment situation Practicing full-time in nursing Practicing part-time in nursing Practicing full-time, not in nursing Practicing part-time, not in nursing Unemployed Work setting Acute care setting Long-term care facility Home health care Health department Other N/A Title Staff nurse Nurse manager/supervisor Instructor/educator Nurse practitioner Case manager Other N/A
Name and location of current employer (e.g. Henry Medical Center, Stockbridge, GA)
Are you working in an area that is federally designated as an underserved population? No Yes
Are you working with a medically underserved population? No Yes
Are you working in an area with a health profession shortage? No Yes
Certification in national nursing specialties
Membership in professional organizations (e.g. ANA, GNA, AACCN,AORN, APHA)
Number of continuing education programs attended since initial nursing graduation None 1-5 6-10 11-15 16-20 Over 20
Number of professional journals you routinely read a month None 1-3 4-6 7-9 10 or more
Program, school and location of initial nursing education (e.g. ASN, Clayton State College, Morrow, GA)
Other degree(s) held, school and location (e.g. Bachelor in another field, Masters, Doctorate)
How long since initial graduation with your basic licensure nursing degree/diploma 0-2 years 3-5 years 6-10 years 11-15 years 16-20 years Over 20 years
How long after initial nursing graduation did you accept your first nursing position Already employed in nursing at time of graduation 0-3 months 4-6 months 7-12 months Not employed in nursing at this time Not seeking employment in nursing at this time
Level of satisfaction with nursing as a career Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Dissatisfied
Describe how successful your education in Clayton State's nursing program was in preparing you for your first clinical experience or current work situation.
How helpful was your clinical experience in preparing you for your initial nursing position Very Helpful Helpful Not Helpful Undecided
How helpful was your classroom experience in preparing you for your initial nursing position Very Helpful Helpful Not Helpful Undecided
How helpful was the nursing curriculum in preparing you for your nursing career Very Helpful Helpful Not Helpful Undecided
How helpful were the ERI exams in helping prepare you for the NCLEX exam Very Helpful Helpful Not Helpful Undecided
Are the computer technology skills you gained helpful to you in your current position Very Helpful Helpful Not Helpful Undecided
Identify the strengths and limitations of Clayton State's nursing program.
Career and/or personal news that you wish to share.