Date:
-
Month
-
Day
Year
Date
Level 4
Spring 2024
This information is used for state and federal reporting. Thank you for taking the time to fill this form out. Your answers will be kept confidential. Note that your name is not requested.
Age:
*
16-20
21-25
26-30
31-40
41-50
51-60
61+
Gender:
*
Female
Male
Marital Status
*
Single
Married
# of Dependents
*
0
1
2
3
4
5
Other
Ethnic Origin:
Caucasian
Hispanic
Native American
African American
Other
What State or non-US Country were you born in?
Are you an international student (i.e. not a US citizen or permanent resident)?
Yes
No
What is your first language?
While in college, where do you live?
on campus
off campus
Other
Please list the types of financial aid and or scholarships you are receiving.
Prior to entering the nursing program were you working?
full time (40+ a week)
part time (1-35 hours a week)
no
Other
Student Residency
In-state resident
Out-of-state resident
Other
Military Information
active duty
military dependent
reserve duty
veteran
not applicable
Are you working now that you are in Nursing School?
full time (40+hrs a week)
part time (1-35hrs a week)
no
Other
Submit
Should be Empty: