Online SANE Training Application
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Home Phone
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Cell Phone
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Preferred E-mail
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example@example.com
Employment Information
Company Name
Work Address
Street Address
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State / Province
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Work Phone
Please enter a valid phone number
What type of agency do you work for? (Check all that apply)
Hospital
Community health setting
University/education setting
Existing SANE program
Rape Center
Police
Prosecuter"s office
Other
If you checked, community health setting, please name below
What type of work involving sexual assault have you done prior to the training?
*
Have you had any experience with speculum insertion in any setting?
*
No
Yes
Do you want to work in a SANE program?
*
Yes
No
Uncertain
If you answered no or uncertain above, please list reason below
Is there anything else you would like us to know about your experiences?
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Education
Highest Level of Education
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Associate Degree (RN)
Diploma (RN)
BSN
Other Baccalaureate Degree
MSN
Other Master
PhD
Other Degree(s)
Certifications (please list)
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Demographics
Gender
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Female
Male
Citizenship
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US Citizen
Non-resident Alien
Permanent Resident
Marital Status
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Married
Single
Divorced
Separated
Widowed
Race
*
American Indian or Alaska Native
Asian/Pacific Islander
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
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Not Hispanic or Latino
Hispanic or Latino
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Computer Skills
Online courses require some basic computer skills. Please tell us what functions you are comfortable executing on your computer. (Check all that apply)
Internet
Connect to internet
Browsers, navigation, searching
Email
Send/Receive, Reply/Forward
Attaching files to an email, downloading attachments from an email
Files
File locations, file folders, directories
Save As, file types, file extensions (.doc, .txt, .pdf, etc.)
File size (KB, MB) acceptable for emailing
Group Communication Tools
Bulletin board
Discussion board
Chat room
Software (Please indicate program and skill level for each application)
Word processing
Please Select
High
Moderate
Minimal
None
Specify Word processing program
Spreadsheets
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High
Moderate
Minimal
None
Specify spreadsheets program
Database
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High
Moderate
Minimal
None
Specify database program
Presentation graphics
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High
Moderate
Minimal
None
Specify presentation graphics program
Is this your first online course?
*
Yes
No
Why did you want to take this course?
*
What do you expect to gain by taking this course?
*
Have you taken previous SANE training (prior to the one at Duquesne University)?
*
Yes
No
If yes, please provide where and when SANE training was taken
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Preceptor
Do you have access to a mentor (nurse practitioner, midwife, SANE, MD, etc.) to provide a preceptored experience for you to learn speculum insertion?
*
Yes
No
If yes, please list credentials of preceptor and type of setting
Would you like assistance with identifying a preceptor and setting up a clinical experience to learn speculum insertion?
Yes
No
After completing this course and preceptored experience, do you plan to take the IAFN certification exam?
*
Yes
No
SANE Program
Do you currently have an operating SANE program in your area?
*
Yes
No
Uncertain
Is there interest in starting a SANE program in your area?
Yes
No
Uncertain
Are you currently working to develop a SANE program?
Yes
No
Uncertain
SART Program
Do you have a SART program in your area?
*
Yes
No
Uncertain
Is there interest in starting a SART program in your area?
Yes
No
Uncertain
Are you currently working to develop a SART program?
Yes
No
Uncertain
Additional Comments
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