VNA/VNF Student Project Distribution Request Form
Thank you for your interest in requesting VNA/VNF support for distribution of your project survey or related recruitment materials. We prioritize projects conducted by nurse members and those that clearly align with the VNA/VNF mission and strategic imperatives. To be considered, please complete this form in full and provide all required documentation. Submission of this form does not guarantee approval. If approved, VNA/VNF will determine the most appropriate method of distribution based on the information provided. Distribution support is reviewed based on eligibility, mission alignment, project readiness, and organizational capacity.
Applicant Identity
Full Name
*
First Name
Last Name
Email
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a licensed nurse?
*
Please Select
Yes
No
Nursing credentials
VNA membership status
*
Please Select
Member
Non-member
VNA member ID
Program of study
*
Please Select
Doctor of Nursing Practice (DNP)
Master of Science in Nursing (MSN)
Doctor of Philosophy (PhD)
Bachelor of Science in Nursing (BSN)
Other
If Other, please specify
Institution / University
*
Faculty Sponsor/Advisor Name
*
Faculty Sponsor/Advisor Email
*
example@example.com
Faculty Sponsor/Advisor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Project Overview
Project Title
*
Brief Project Purpose
*
How does this project align with the VNA/VNF mission and strategic imperatives?
*
Population & Eligibility
Target population
*
Geographic area/Setting
*
IRB & Documentation
IRB Status
*
Please Select
IRB approved
IRB exempt
IRB not required
Pending review
Quality Improvement, IRB N/A
Upload IRB Approval Letter, Exemption Letter, or Supporting Documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Survey & Instrument Information
Survey or instrument title
*
Survey link
If no survey link, upload instrument document.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Estimated time to complete the survey or instrument
*
Please list the types of data fields being collected
*
Will any personally identifiable information be collected?
*
Please Select
Yes
No
If yes, please describe what identifiable information will be collected and why
Recruitment Request
What distribution channel(s) are you requesting?
*
Email
Newsletter
Social Media
Website
Other
If Other, please specify
Number of recruitment waves requested
*
Please Select
1
2
3
4
5+
Preferred distribution date(s)
*
Requested open date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Requested close date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reminder date(s), if requested
Draft outreach copy
*
Outputs & Commitments
Do you agree to provide a report-out of findings to VNA/VNF after analysis?
*
Please Select
Yes
No
Please describe your plan for reporting findings back to VNA/VNF
*
Do you agree to submit an abstract as a Rapid Fire and/or Poster presenter at an upcoming VNA/VNF conference, or submit an article?
*
Please Select
Yes
No
Not applicable
Please describe your dissemination plan
*
Please confirm the following statements
*
I confirm that all necessary safeguards are in place for the survey or instrument used.
I understand that VNA/VNF may request updates on dissemination progress.
Final Review
Signature / typed name
*
Date submitted
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Request
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