Form
CNA Readiness Questionnaire
This questionnaire helps us understand your needs so we can recommend the best level of one-on-one support.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
When did you complete your CNA training?
*
Within the lase 3 months
3-6 months ago
6-12 months ago
Over a year ago
Have you taken the CNA Skills exam before?
*
Yes
No
If yes, how many times have you taken the exam?
Once
Twice
More than twice
Have you taken the CNA Knowledge Exam before?
*
Yes
No
If yes, how many times have you taken the exam?
Once
Twice
More than twice
For the Knowledge exam, which topics do you feel you need the most help with or if exam taken, which areas received the lowest scores?
Safety
Infection Control
Residents Rights
Basic Nursing Skills
Care Impaired
Data Collection
Disease Process
Mental Health
Personal Care
Roles and Responsibilities
Communication
Age Process and Restorative Care
Death and Dying
Which do you feel you need the most help with?
*
Knowledge
Skills
Test Anxiety
I'm not sure
How confident do you currently feel about taking the CNA exam?
*
Very confident
Somewhat confident
Not very confident
Extremely nervous or overwhelmed
What do you feel you need the MOST help with right now?
*
Reviewing CNA knowledge
Skills practice
Understanding exam expectations
Test-taking strategies
Building confidence
Creating a study plan
When are you hoping to take (or retake) the CNA exam?
*
Within the next 2 weeks
Within 1 month
1-2 months
Not sure
What is your main goal for joining the CNA Readiness Program?
Preferred session format
*
In-person
Virtual
Either
How soon would you like to start the program?
*
One Week
Two Weeks
Three Weeks
Not Sure
Best availability for one-on-one sessions
*
Weekdays
Evenings
Weekends
Mixture
What is your learning style?
Visual Learner
Auditory Learner
Kinesthetic Learner (Hands-on)
Reading/Writing Learner
Is there anything else you would like us to know about your situation or concerns?
Submit
Should be Empty: