Fall 2022
Level 1
Date:
-
Month
-
Day
Year
Date
The following information is required for reporting purposes. 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
American Indian and Alaska Native
Black/African American
Asian
Native Hawaiian or other Pacific Islander
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?
no
yes, full time (40+ a week)
yes, part time (1-35 hours a week)
Other
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
Submit
Should be Empty: