Directions: Please complete the answer which applies to you.
1. Year of graduation
2. Initial Nursing Preparation:
3. Previous academic preparation (check all that apply):
Bachelor of Science in Nursing
Baccalaureate Degree in
Master of Science in Nursing (Specify specialty )
Master of Science (non-nursing) - (Please specify )
Post Master’s Study in Nursing
Post Master’s Study (non-nursing)
4. Student status for graduate study: full time part time
5. Employment status while a graduate student:
full time (Nursing) part time (Nursing)
full time (non-Nursing) part time (non-Nursing)
6. Were you a Graduate Assistant? Yes No
7. Gender: male female
8. Current Age:
9. Marital status: single married divorced widowed
10. Number of children:
11. Licensed in: PA NY NJ other (please specify) not currently licensed
12. Current professional position:
Position title: Unit:
Name of Employer (if applicable):
Length of time in current position:
length of time in this position
List main reason for not being employed in nursing:
How long have you been seeking a job?
What percent of your employment time is spent in each or/the following areas?
% Clinical Practice (Direct Care)
% Administrative responsibilities
% Formal Teaching
13. Check those incentives that encouraged you to remain in your current job
14. In what professional position were you employed immediately upon graduation from
the Master’s program?
Position title Time spent in position
15. Number of positions you’ve held since graduation:
16. In what size community do you work:
17. Where do you work?
18. Range of current earnings (optional):
A. Full Time
B. Part Time
19. At this point in your career, how do you rate the adequacy of your nursing education?
A. Classroom learning
B. Clinical experience:
20. Evaluate how much this program helped you to develop the following skills using
the following scale:
(1) Very helpful (2) Helpful (3) Minimally helpful (4) Minimally helpful (5) Not at
Ability to perform therapeutic interventions
Knowledge of developmental tasks and age related changes.
Planning, managing and organizing
Applying learning theory to client education
Sensitivity to the values, rights and needs of others
Ability to act as client advocate
Ability to articulate one’s needs
Interpersonal communication and relationships
Demonstrating accountability for one’s own actions
Increased autonomy and decision-making ability in professional
Creative problem solving
Collaboration with nursing and other disciplines
Writing journals, reports and papers
Accessing information resources (i.e. date bases, VTLS)
Use of time, supplies and other resources
Ethical and morale reasoning
Applying research findings to practice
Integrating cognate and support courses and nursing theory into practice
Continuous quality improvement based on standards of practice
Maintaining standards of professional practice
Practice within the legal parameters of the profession
Identify health care resources available for client’s needs
Ability to function in the professional nursing role
21. What is the highest degree earned since graduation?
22. List certifications (local, state or national). Include name of certifying agency
and year certified.
23. Professional Organization Memberships (please check all that apply)
American Nurses’ Association
National League for Nursing
Sigma Theta Tau
24. Have you participated in and/or provided leadership in formulating directions
for health care locally? Statewide? Nationally? (e.g. committee membership, legislation).
25. In what ways have you participated in research activities?
26. List publications and presentations.
27. Please list your significant community/civic/other activities.