Membership Engagement Committee
Interest Survey
Name
*
First Name
Last Name
Email
*
example@example.com
Home Town/City
*
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your practice specialty(s)?
*
Adult Primary Care
Family Practice
Pediatrics
Acute Care/Inpatient
Behavioral Health
Urgent Care
Specialty Practice
Other
How many years have you worked/been working as a Nurse Practitioner?
*
I am still a Student
< 1 to 5
6 to 10
11 to 15
16 to 20
21 to 25
26 to 30
> 30
Please select the option(s) below that best describes your current practice setting:
*
Smaller group or private practice that employees 5 or less NPs
Larger practice or organization that employees many NPs
Academic Medical Center
Academic Institution as Nursing Faculty
Not currently in practce
Other
Preferred day(s) of week for a Zoom meeting?
*
Mondays
Wednesdays
Thursdays
Preferred time(s) of day for a Zoom meeting?
*
5:30 PM to 6:30 PM
6:30 PM to 7:30 PM
Other
Please indicate if you are active on any of the following social media platforms:
*
Facebook
Instagram
LinkedIn
TikTok
X
Not active on social media
Please indicate which, if any, of MCNP's social media pages you follow:
*
Facebook
Instagram
LinkedIn
X
Not following any MCNP pages
Have you previously attended any MCNP events or regional dinner programs?
*
YES
NO
If yes, please share which events (e.g. annual conference, transition to practice) or region for regional dinner programs:
Additional comments or information you would like to share:
Submit
Should be Empty:
