Gerontological Nurse

Gerontological NurseDemographic and Employment Information81. Location of facility:UrbanRuralSuburbanOutside the U.S.2. Average number ofpatient encounters/visits peryear at your primary place ofemployment:≤1,0001,001 – 5,0005,001 – 10,00010,001 – 20,00020,001 – 40,00040,001 – 60,00060,001 – 80,00080,001 – 100,000>100,0003. Will you receive amonetary reward/compensation from youremployer for certification?Yes NoIf yes:$ ______________ per hour$ ______________ per year$ ______________ one time4. Number of individualsyou supervise:_______________________5. Years of experience asa registered nurse/licensedpractitioner (round to nearestwhole year):_______________6. Total years of experience inthe field in which certificationis desired (round to nearestwhole year):_________________________7. Primary place ofemployment (check one):Ambulatory carePhysician-managedgroup practiceHome healthHospiceHospitalManaged careNurse-managedgroup practiceNursing home/long-term careOccupational health/environmental healthOffice nursingPublic health/communityhealthSchool healthSchool of nursing/university/collegeFederal/militaryOther:__________________________8. Patient population/conditions representativeof your practice (check allthat apply):Medical-SurgicalCardiacEndocrine/DiabetesPulmonaryNeurologyRenal/UrologyOrthopedicsRehabilitationGerontology/Long Term CarePerinatalPost-partumLabor & DeliveryPediatricsERTraumaCritical CareOther:_________________9. Age range of yourprimary patient population:0–12 – 2122 – 6566+10. Average number ofhours worked per week:8 or fewer9–1617–2425 – 3233 – 40>4011. Size of facility(total number of beds):N/A1 – 100101 – 250251 – 500>50012. Is certification partof your employer’s jobperformance/clinicalladder rating criteria?Yes No13. How did you obtainthis application?From ANCC websiteMailed from ANCCFrom my schoolFrom my workplaceAt a tradeshowOther:__________________________14. Please check the professional organizations in which you are a member (check all that apply):AACVPR American Association of Cardiovascularand Pulmonary RehabilitationAADE American Association of Diabetes EducatorsAAACN American Academy of Ambulatory Care NursingACNP American College of Nurse PractitionersADA American Diabetes AssociationADA American Dietetic AssociationANI Alliance for Nursing InformaticsAPhA American Pharmacists AssociationAPNA American Psychiatric Nurses AssociationAPHA American Public Health Association(Public Health Nursing Section)ANA American Nurses AssociationOther Demographic InformationASPMNISPNNACNSNCGNPNGNANNSDOPCNASPNSVNOther:American Society for Pain Management NursingInternational Society of Psychiatric-MentalHealth NursesNational Association of Clinical Nurse SpecialistsNational Conference of GerontologicalNurse PractitionersNational Gerontological Nursing AssociationNational Nursing Staff Development OrganizationPreventive Cardiovascular Nurses AssociationSociety of Pediatric NursesSociety for Vascular Nursing__________________________________________9Note: Providing the following information is strictly voluntary.It will be used for statistical purposes only.Sex: M FDate of Birth: __________________________________________month/date/yearRace/Ethnic GroupAmerican Indian/Alaska NativeAsian/Pacific IslanderBlack/African-AmericanHispanicWhite/CaucasianNative HawaiianOther:__________________