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* 1. First Name

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* 2. Last name

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* 3. Gender

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* 4. What is your ethnicity and race?

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* 5. Please mark the answer that best describes your citizenship.

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* 6. Age

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* 7. Birth year

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* 8. Mailing Address

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* 9. City

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* 10. State

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* 11. Zip Code - Please include the 4 digit extension Zip Code which can be found by typing your address in at www.usps.com

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* 12. Cell Phone number

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* 13. Home phone number

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* 14. Email Address  (please include your permanent or non-school email you check regularly)

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* 15. What is the name of your nursing school?

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* 16. Please select the type of education training you are enrolled in?

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* 17. What is your anticipated date of graduation (month and year)?

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* 18. What is your student enrollment status?

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* 19. What is your current academic year?

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* 20. What type of nursing program are you in?

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* 21. Has your clinical training been in a Primary Care (PC) setting? PC setting is defined as a facility providing accessible health services by clinicians who are accountable for addressing a large majority of personal health care needs, practicing in the context of family and community. if yes, how many clock/contact hours?

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* 22. Has your clinical training been in a Medically Underserved Community (MUC) setting? MUC defined as a geographic location or population of individuals that is eligible for designation by a state and/or the federal government as a Health Professions Shortage area (HPSA), Medically Underserved Area (MUA) or Medically Underserved Population (MUP). If Yes, how many clock/contact hours?

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* 23. Have you received any training in the following at your clinical sites? (Select all that apply)

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* 24. Have you received any training in Telehealth?

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* 25. Has your clinical training been in a Rural setting? Rural is a geographical area that is not part of a Metropolitan Statistical Area (MSA). If yes, how many clock/contact hours?

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* 26. What are your post graduation intentions?

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* 27. If employed, current employment status

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* 28. If employed, please select the type of employment

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* 29. If Employed, please state your current position, location and title

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* 30. Please select your employment location

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* 31. Number of years as a nurse (for RN-BSN students only)

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* 32. Are you a veteran?

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* 33. Would you describe yourself as having an Educationally Disadvantaged Background? Educationally Disadvantaged: coming from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills and abilities necessary to develop and participate in a health professions education or training program.

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* 34. Would you describe yourself as having an Economically Disadvantaged Background? Economically Disadvantaged: coming from a family with annual income below a level based on low-income threshold established by the U.S. Census Bureau. Please select option that best fits you. For each additional person add $10,760

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* 35. Are you eligible for a Pell Grant?

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* 36. Would you describe yourself being from a rural background? Rural is a geographical area that is not part of a Metropolitan Statistical Area (MSA).

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* 37. Which types of vulnerable populations have you served during clinical? (Select all that apply)

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* 38. Choose any social support services you have received in school (Select all that apply)

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* 39. Choose all academic support services received in school (Select all that apply)

Please answer the questions below to the best of your ability. Your responses to the following questions will allow us to pair you appropriately with a mentor.

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* 40. Please identify all of your clinical sites during the funding year 07/01/24 - 06/30/2025? (Select all that apply)

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* 41. Select the type of setting where the site was located (Select all that apply)

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* 42. What benefits do you see from participating in a mentoring program?

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* 43. What was your motivation in choosing to go to nursing school?

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* 44. What concerns you most about nursing school?

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* 45. What challenges/barriers might you encounter during nursing school that may interfere with completing your degree?

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* 46. What are your professional goals?

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* 47. What specialty do you anticipate choosing upon graduation?

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* 48. If you had to describe the ideal mentor to help you meet your goals, what characteristics would this person have?

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* 49. Do you prefer a mentor of a certain ethnic/racial background? If so, please specify.

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* 50. Do you have any other comments that you would like to share?

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* 51. Write a 500 word essay (maximum) answering this question: Why should you be given this opportunity and how will it help you be successful? Please type your essay here.
If you are having problems, please email Shemeza@coloradonursingcenter.org

By signing below, I agree to the program requirements listed in the application information sheet. 

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* 52. Applicant Signature (Your typed name will be considered your official signature).

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* 53. Date

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