Date:
-
Month
-
Day
Year
Date
Fall 2020 Pre-Licensure BSN Level 1
Your answers will be kept confidential. Please note that your name is not requested.
Age:
*
16-20
21-25
26-30
31-40
41-50
51-60
Gender:
*
Female
Male
Marital Status
*
Single
Married
# of Dependents
*
0
1
2
3
4
5
Other
Ethnic Origin:
*
Caucasian
Hispanic
Native American
African American
Asian
Other
Do you anticipate a need for tutoring? If so, what areas?
Do you have difficulty with:
speech
sight
hearing
Other
What CITY were you born in?
What STATE were you born in?
What is your first language?
While in college, where do you live?
on campus
off campus
Other
Please list the types of financial aid you are receiving
Why did you decide to go into Nursing?
Prior to entering the Nursing Program were you working?
yes
no
full time (40+ a week)
part time (1-35 hours a week)
How may hours a week do you work now?
40 +
39--31
30-21
20-11
10-1
0
Student Residency
In-state resident
Out of state resident
Other
Military Information
active duty
military dependent
reserve duty
veteran
not applicable
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