Member Request FormStrengthening Forensic Nursing: A Re LAB Project

Member Request Form

Strengthening Forensic Nursing: A Re LAB Project

Thank you for your interest in Strengthening Forensic Nursing: A Re LAB Project.

Please complete the survey below.

Contact Information

First Name*

Last Name*

Preferred Name

Phone*

Phone

Email*

Secondary email

Demographic Information

Race*

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American Indian/Alaska Native

Asian

Black/African American

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White

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Ethnicity*

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Hispanic or Latino/a

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Gender*

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Female

Male

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Communities You Belong To

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First generation college student

LGBTQIA+ community

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BIPOC

What is the zip code where you live?*

What is the zip code where you work?*

Communities You Serve

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LGBTQIA+ community

Rural

Tribal

Multi-lingual

BIPOC

SANE Development

Are you a licensed RN or NP?*

Yes

How many years have you been practicing as a licensed RN or NP?*

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less than 2

2-5

Current School/Education Program, if applicable

Current Employer(s), if applicable

Are you employed as a SANE or by a SANE program?*

Yes

Have you completed a 40-hour SANE didactic course?*

Yes

Have you completed a clinical skills lab?*

Yes

Are you pursuing certification or recertification as a SANE-A or SANE-P?*

Yes

What makes you interested in SANE practice? Please respond in a few sentences.*

What areas of SANE practice are you most hoping for support with? Please respond in a few sentences.*

What areas of SANE practice do you find most challenging or have concerns about? Please respond in a few sentences.*

How did you hear about the UMN SANE: A Trauma Informed Community of Practice program?*

SANE Colleague

Employer

Other

SANE Colleague*

Referring Employer*

Other Referral Source*

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