PROFILE OF FACULTY IN PROGRAM (GROUP) MEMBERSHIP

Please have each faculty member complete the following profile questions.
(Reproduce for additional copies)

Name:____________________________________________________________________________________

Preferred Mailing Address:_____________________________________________________________________

_________________________________________________________________________________________

City:_______________________________________ State:___________  Zip:___________________________

Tel:___________________ Fax:___________________ Email:________________________________________

Title/Position:_______________________________________________________________________________

Your percentage of time in faculty position (e.g. 100%, 50%)_____________________

Your highest level of education: 

	Baccalaureate  Masters   Doctorate   Post-Masters   Other (specify):_____________________

Number of years in current teaching position:______________

Total number of years as a nurse practitioner:______________

	NP specialty area of practice (i.e., family):_________________________________

	Do you practice clinically?   Yes   No

 		
		As part of teaching job

		As a separate (paid) job

		Other (specify):____________________________________________ 

		Approximate numbers of hours per week in clinical practice:___________

		Please describe your practice setting and type of practice:__________________________________

		______________________________________________________________________________

Are you involved in research activities?  Yes   No

	 		    
		What is you current project?_________________________________________________________

		_______________________________________________________________________________

Please answer the following questions to help us track the diversity of our membership.

	Gender:	Female   Male

	Age:	25-29  30-39  40-49  50-59  60-65  66+

Please identify your race/ethnicity.  Select one or more as appropriate.

American Indian or Alaska Native	Asian		Black or African American

Hispanic or Latino	Native Hawaiian or other Pacific Islander	White

Please include this form with the Application for Program (Group) Membership.