• SANE Pediatric Didactic Course

    Contact Information
  • At which point are you applying to this program? Please select which describes you and your plans best. Please note that all enrolled nurses will complete all components of the program, but may start at different entry points.*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Demographics

  • Are you currently employed full or part time?*
  • Please select the response below that best describes your veteran status?*
  • Gender*
  • Citizenship*
  • Race*

  • Education

  • Please select all degrees that you have received*
  • DU student/employee*
  • Currently employed?*
  • Do you currently work in a facility in which you will have access to patients of sexual assault in order to obtain your pediatric SANE-related practice hours after completing the didactic course and the 3-day Clinical Preceptor Course?*
  • Do you currently have access to a Pediatric SANE preceptor at your facility?*
  • Do you have access to a mentor (nurse practitioner, midwife, SANE, MD, etc.) to provide a preceptored experience for you to learn speculum insertion?*
  • Are you currently working in a pediatric SANE program?*
  • Do you currently have an operating pediatric SANE program in your area?*
  • Which of the following describes your practice site?*
  • If not working in a CAC, is your facility associated with a CAC? *
  • Have you completed an adult/adolescent SANE didactic course?*
  • If yes, when did you complete your adult/adolescent SANE didactic course?
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  • If yes, are you certified adult/adolescent SANE (i.e. SANE-A)?
  • Are you currently practicing as an adult/adolescent SANE nurse, whether or not you're certified?*
  • Is this your first online course?*
  • How did you hear about our program?*
  • Signature Date*
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  • Should be Empty: