Demographic Form for the Master of Science in Nursing

University of North Carolina Wilmington School of Nursing

Please identify the MSN Option for which you seek admission:

Family Nurse Practitioner ______

Nurse Educator   ________

Name                                                                                                                                                                                                          .

                                                Last                                                         First                                        Middle

Residence:

Address                                                                                                                                                                                                     .

                                                Street

                                                                                                                                                                                                     .

                                                City                                         State       Zip                          County                   Country

Employment:

Address                                                                                                                                                                                                      .

                                                Street

                                                                                                                                                                                                    .

                                                City                                         State       Zip                          County                   Country

Home Phone  (          )                                                             Work Phone   (        )                                                            .

Social Security Number*                                                                                          .

*Disclosure of your Social Security number is purely voluntary. It will be used for administrative purposes only, as your assigned identification number.

Gender**                       Male                       Female

Birthdate**  (Month/Day/Year)                                                                               .

**Information requested only for reporting purposes.

Semester/Year of Expected Entrance                                                                      .

�    Full Time      (or)          �  Part Time

1.  Do you have demonstrable computer skills, including ability to use electronic mail, a web browser, and a word processing program?              Yes                     No

     Do you own a computer?             Yes                     No

If Yes, indicate type, amount of RAM, size of hard-drive, modem capabilities, programs installed, etc.

                                                                                                                                                                  .

                                                                                                                                                                                 .

2.  Do you have access to a computer in close proximity to where you will study?

                              Yes                    No  e-mail address                                                                                 

3.  The Federal government requires institutions of higher education receiving federal assistance to report minority group student enrollments. The information requested here will assist in meeting this requirement and will provide statistical data for the university. Please check the appropriate line:

                          American Indian or Alaskan Native                              White (Not of Hispanic Origin)

                                          Black (Not of Hispanic Origin)                                        Asian or Pacific Islander

                                          Hispanic                                                                               Other (Specify)

4.  Is English your first (native) language?          Yes              No.

     What language(s), other than English do you speak?                  .

5.  Sigma Theta Tau membership, as an undergraduate?           Yes             No.

                Other honorary membership(s) (Specify)                                                                                    .   Overð

NURSING EXPERIENCE:

1.  Do you currently hold an active license to practice as a Registered Nurse?               Yes                     No

If Yes; what state(s)?                                                                                                                                .

If Yes; Certificate number(s)?                                                                                                                  .

Years of RN experience.  Full Time                                Part Time                              .

2.  Type of agency in which you work/have worked:  (Within the past two years, check all that apply.)

       Community Health Center                        Physician’s Office

       County Health Department                       Rural Health Clinic

       Hospital                                                          School

       Occupational Health                                    School of Nursing

       Migrant Health Clinic                                 Nursing Home

       Other (Specify)                                                                                                                                                                .

3.  Population served/Nature of experience:  (Check all that apply.)

       Infants; # of years                 .                       Adults; # of years                 .

       Children; # of years                .                     Elderly/Older Adults; # of years                 .

       Women; # of years                .                        Pregnant Women; # of years                 .

       Adolescents; # of years                .

4.   Percentage of medically underserved and/or minority population(s) served:  (Check all that apply.)

    Low income                  %.                                                Elderly                  %.

                    African Americans                  %.                                   Hispanics                  %.

       Native Americans                  %.                                   Migrants                  %.

       Other (Specify)                  %.

Please provide a current curriculum vita /resume, in a format to indicate the following:

(Please be as specific and detailed as possible, listing information in reverse chronological order.)

1.   Formal education.

2.   Professional experience, describing its clinical and/or administrative characteristics.

3.   Any/all continuing education you have completed.

4.   Any/all honors, awards, and/or certifications you have received.

5.   Any/all community/regional activities in which you are involved/participate.

6.   Volunteer activities—briefly describe, if applicable.

7.   Publications—if applicable.

8.   Research—if applicable.

9.   Organizational leadership—briefly describe, if applicable.

10. Memberships—briefly describe, if applicable.

I certify that the information on this survey is complete.

APPLICANT’S SIGNATURE                                                                         Date                                     .

Please return completed Survey Form and curriculum vita/resume directly to:

                Student Services Director

UNCW School of Nursing

601 South College Road

Wilmington, NC 28403-5995                                                         

(Up-dated 2/07)                                   End