Campus SANE Network Program Application
Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number
Preferred Email
*
user@duq.edu
Preferred Home Mailing Address
*
Preferred Home Mailing Address
Preferred Home Mailing Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
When would you want to start the SANE Course?
*
Please Select
6-Hour Supplemental Training Only
Are you interested in 6-Hour Supplemental Training Only?
Yes
No
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Campus Information
Name of College or University where you are employed
*
What department do you work in?
*
Address of College/University
*
Address of College / University
Address of College / University 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Work Phone Number
*
Please enter a valid phone number
Employed by College/University or Contractor?
*
College/University
Contractor
Employment level
*
Full-time
Part-time
Casual
Other
Is there a hospital within 5 miles of your institution?
*
Yes
No
Which hospital do you commonly refer students to?
*
Are there any registered SANEs currently working at your college/university?
*
Yes
No
I don't know
How many nurses work at your campus health services?
How many full-time employees work at your campus health center?
Do you have existing funding to improve the sexual assault response on your campus?
Yes
No
I'm not sure
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Education and Experience
Degrees Earned
*
Highest Degree Earned
*
Please Select
Associate Degree
Bachelor's Degree
RN
PA
Master's Degree
Doctoral Degree
Are you a licensed RN?
*
Yes
No
If so, in what state?
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
How many years have you been a nurse?
*
How many years have you been a campus-based nurse?
*
Have you taken a SANE course before?
*
Please Select
Yes
No
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Demographics
All demographics are collected for grant reporting purposes.
Gender
*
Male
Female
Non-binary
Prefer to self-describe
Citizenship
*
Please Select
US Citizen
Non-resident Alien
Permanent Resident
Marital Status
*
Please Select
Married
Single
Divorced
Separated
Widowed
Race
*
Please Select
White
Black or African American
American Indian
Alaska Native
Asian
Native Hawaiin or other Pacific Islander
More than one race option applies to me
Ethnicity
*
Please Select
Hispanic or Latino
not Hispanic or Latino
Age
*
Please Select
18-24
25-34
35-44
45-54
55-64
65+
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INTEREST/MOTIVATION
What do you hope to gain by taking this course?
*
Do you currently have an operating SANE program on your campus?
*
Yes
No
I don't know
Do you have a Sexual Assault Response Team (SART) program at a nearby hospital or on your campus?
*
Yes
No
I don't know
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OTHER/COMMITMENT
How did you hear about our program?
*
If accepted into the program, are you willing to commit to stay in communication with program staff regarding progress of course, continuing education opportunities, etc.?
*
Yes
No
Questions
Submit
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