NURS 5726 Course Application

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Application for NURS 5726: Sexual Assault Nurse Examiner (SANE) Trauma-Informed Care Clinical Experience

The course, offered through the University of Minnesota - Twin Cities School of Nursing, is designed to provide SANE nurses with supported clinical experience. Our clinical partners are the Regions SANE program (adult/adolescent) and the HART program (pediatrics, adult/adolescent).

Participants commit to staying in the Twin Cities area (Minneapolis-St. Paul MN) for 5 to 10 calendar days, with the majority of that time serving on-call. When preceptors receive a call to attend a case, the participant will meet the preceptor at the case location, and work on the case alongside the preceptor. Participants will work with multiple preceptors, and may attend cases in multiple locations. Due to the nature of sexual assault response work, it is unknown how many cases each participant will attend. Participants will engage in supplemental work before, during, and after the clinical experience.

This form is the application to participate in NURS 5726. At this time, the clinical experience can only accommodate one participant at a time. Participants will be accepted based on eligibility, availability, and the priorities of the HRSA SANE Workforce development program.

First Name

* must provide value

Last Name

* must provide value

Phone Number

* must provide value

Please re-enter your email

* must provide value

Your emails do not match. Please correct your entry. When it is correct, select "confirm".

confirm

reset

Race

* must provide value

American Indian or Alaska Native

Asian

Black / African American

Native Hawaiian / Other Pacific Islander

White

More than One Race

Prefer not to say

reset

Ethnicity

* must provide value

Hispanic or Latino/a

Not Hispanic or Latino/a

Prefer not to say

reset

Gender

* must provide value

Female

Male

Nonbinary / Two-Spirited

Prefer not to say

reset

What is the zip code where you live?

* must provide value

Communities you belong to

Rural

Tribal

LGBTQIA+

Multilingual

BIPOC

Do you have an active RN or NP license?

* must provide value

Yes

reset

How many years have you been practicing as a licensed nurse?

* must provide value

less than 2

2-5

reset

Have you completed the 40-hour didactic training and the clinical skills lab for SANE nursing?

* must provide value

Yes

reset

Please share when (month, year) and where you completed your 40-hour didactic training and what organization hosted this training.

* must provide value

Expand

Please share when (month, year) and where you completed your SANE clinical skills lab and what organization hosted this training.

* must provide value

Expand

What patient population do you, or you do plan to, serve as a SANE?

Adult/adolescent

Pediatric

Both

Approximately how many SANE cases have you had so far?

1-4

reset

Are you pursuing certification or recertification as a SANE-A or SANE-P?

* must provide value

Yes

reset

Are you able to physically stay in the Twin Cities area and travel to clinical sites for the clinical section of this course (please note: funding is available for travel and lodging)?

Successful clinical completion requires 5 to 10 calendar days on-call.

* must provide value

Yes

reset

I am willing and able to meet the School of Nursing compliance requirements of clinical placement. I understand that the course clinical partners require COVID-19 vaccination compliance, which includes booster vaccinations, and that exemption waivers for COVID-19 vaccination will not be accepted.

* must provide value

Yes

reset

I understand that Strenthening Forensic Nursing: a RE Lab Project can only reimburse the costs associated with the SANE residency (tuition, academic fees, lodging, transporation, meals) for completed SANE residency experiences. I understand that I will be responsible for costs incurred if I do not complete the SANE residency.

Yes

reset

Do you currently work as a SANE?

* must provide value

Yes

reset

Name of Employer

* must provide value

City of Employment

* must provide value

State of Employment

* must provide value

Zip Code of Employer

* must provide value

Communities you serve

Rural

Tribal

LGBTQIA+

Multilingual

BIPOC

When are you available to be on-call in the Twin Cities?

The course requires 5 - 10 calendar days. On-call days may be separated into 2 blocks if necessary (for example, 2 weekends of 3 days each). *Note: December/January dates are not available at this time.

* must provide value

February

March

April

May

June

July

August

September

October

November

Please share specific dates you are available during the month(s) you selected.

* must provide value

Expand

How would participation in this course help you in your work as a SANE?

* must provide value

Expand

How did you hear about NURS 5726: SANE Clinical Residency?

* must provide value

SANE Colleague

Employer

Other

reset

SANE Colleague:

Referring Employer:

Other Referral Source:

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.