SANE Pediatric Didactic Course

SANE Pediatric Didactic Course

Contact Information
At which point are you applying to this program? Please select which describes you and your plans best. Please note that all enrolled nurses will complete all components of the program, but may start at different entry points.*

Pediatric/Adolescent Didactic Course: Just beginning, applying to start with Online Pediatric/Adolescent Didactic course;Pediatric/Adolescent Clinical Preceptor Course (CPC): Already have completed a Pediatric or Pediatric/Adolescent Didactic course and applying to come to the 3-day hands-on Pediatric/Adolescent Clinical Preceptor Course (CPC) in Pittsburgh;Pediatric/Adolescent Mentoring Program: Already have completed a Pediatric or Pediatric/Adolescent Didactic course and have been practicing with a pediatric population. I do not need the 3-day hands-on Clinical Preceptor Course (CPC); however, I'm interested in beginning at the Mentoring Program, which includes access to online education sessions and an online Pediatric/Adolescent Review Course in preparation of taking the Pediatric SANE certification exam.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*
Please enter a valid phone number
Cell Phone*
Please enter a valid phone number
Preferred E-mail*
Duquesne Email
username@duq.edu

Education
Please select all degrees that you have received*

DiplomaAssociates DegreeBSNMSNDNPPhDNP
Please list your NP degree*
State of licensure*
Years in practice as a nurse*
What is your nursing specialty or area of expertise?*

Do you currently work in a facility in which you will have access to patients of sexual assault in order to obtain your pediatric SANE-related practice hours after completing the didactic course and the 3-day Clinical Preceptor Course?*

YesNo
If no, please explain
What is the approximate number of pediatric sexual assault cases that come into your facility within in a year?*
Do you currently have access to a Pediatric SANE preceptor at your facility?*

YesNo
If yes, please list credentials of SANE preceptor and type of setting.
Do you have access to a mentor (nurse practitioner, midwife, SANE, MD, etc.) to provide a preceptored experience for you to learn speculum insertion?*

YesNo
If yes, please list credentials of preceptor and type of setting

Please list your nursing certifications:*
What type of work involving sexual assault have you done?*
Please list any previous SANE training programs you have completed, location/institution, and dates of enrollment.*
Are you currently working in a pediatric SANE program?*

YesNo
Are you working in an established SANE pediatric program or will you be developing a new program? *
Do you want to work in a pediatric SANE program?*

YesNo
If you aren't currently working in a pediatric SANE Program and have no plans or desire to do so, please explain why you're applying to this program.
Do you currently have an operating pediatric SANE program in your area?*

YesNo
Is there interest in starting a SANE program in your area?*

YesNo

Additional Comments
Signature*

Clear
Signature Date*

MonthDayYear
By checking this box, I am providing my electronic signature approving all the information entered above.*

Yes
Should be Empty:

Demographics