Qualtrics Survey | Qualtrics Experience Management

Name (First and Last)

What are your preferred pronouns?

What is your race?

Please read the descriptors carefully, so that you can accurately report your race according to Federal classifications. ***Please note that "Hispanic/Latino" or "Non-Hispanic/Non-Latino" is defined as an ethnicity, and must be recorded in addition to your race in the following question

American Indian or Alaska Native - A person having origin in any of the original peoples of North and South America (Including Central America) and who maintains tribal affiliation or community attachment
Asian - A person having origin in any of the original peoples of the far East, Southeast Asian or Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American - A person having origin in any of the Black racial group of Africa
White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
More than One Race (text entry)
I choose to not disclose

What is your ethnicity?

Hispanic/Latino
Non-Hispanic/Latino
I choose to not disclose

Are you an underrepresented minority (URM)?

Underrepresented Minority (URM) is an individual from a racial and/or ethnic group that is considered inadequately represented in a specific profession relative to the numbers of that racial and/or ethnic group in the general population. Note: For the purposes of the health professions, BHW considers individuals who are from the following racial and ethnic backgrounds to be underrepresented: Mark "Yes, I am an underrepresented minority" if you identify as one of the following: Black or African American Hispanic (all races) Native Hawaiian or Other Pacific Islander American Indian or Alaska Native

Yes, I am an underrepresented minority
No, I am not an underrepresented minority
I choose to not disclose

Do you come from a disadvantaged background?

Disadvantaged background is a citizen, national, or a lawful permanent resident of the United States or the District of Columbia, the Commonwealths of Puerto Rico or the Marianas Islands, the Virgin Islands, Guam, the American Samoa, the Trust Territory of the Pacific Islands, the Republic of Palau, the Republic of the Marshall Islands and the Federated State of Micronesia who either: Comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; -OR- Comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary, HHS, for use in health professions and nursing programs.

Yes, I come from disadvantaged background
No, I do noncom from a disadvantaged background
I choose not to disclose

What is your email address?

What is your phone number?

What is your specialty?

What is your advisor's name?

What is your expected graduation date?

What is your current GPA (4.0 scale)?

Are you from or have ever lived in a rural area?

Yes
No

Do you have a rural location preference for clinical rotations? (If so, where?)

Why do you want to participate in the Rural Health Focus Area and how your background will contribute to future practice in rural health? (limit to 600 Words)

Please list languages other than English that you speak AND list your level of proficiency.

Basic: I speak the language imperfectly and only to a limited degree and in limited situations. I have difficulty in or understanding extended conversations. I am unable to understand or communicate most healthcare concepts.

Fair: I speak and understand well enough to have extended conversations about current events, work, family, or personal life. Native speakers notice many errors in my speech or my understanding. I have difficulty communicating about healthcare concepts.

Advanced: I speak very accurately, and I understand other speakers very accurately. Native speakers have no problem understanding me, but they probably perceive that I am not a native speaker Native/functionally native: I converse easily and accurately in all types of situations. Native speakers, including the highly educated, may think that I am a native speaker, too.

Example: English - Native, Spanish - Fair, Farsi – Advanced

Please upload an updated CV/Resume

Acknowledgement from your Faculty Advisor

Please leave any additional information that you would like us to know.

By submitting this application, I acknowledge and agree to the following:

Clinical intensives for the academic year 2023-2024 will be 2 weeks upon completion of the Rural Health Seminar course.

If, at any point, I am no longer in good academic standing or do not complete the required clinical hours, my participation in the focus area will be re-evaluated.

Transportation costs may be covered by the OSHPD grant at the Department of Family Healthcare Nursing for FNP students.

I acknowledge and agree.