• 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?*
  • Have you come from an environment that has inhibited you from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions or nursing school?*
  • Have you come from a family with an annual income below that listed in the table below, based on number of persons residing with you?*
  • Persons in household Annual Income
    1 $24,980
    2 $33,820
    3 $42,660
    4 $51,500
    5 $60,340
    6 $69,180
    7 $78,020
    8 $86,820
  • Gender*
  • Citizenship*
  • Marital Status*
  • Race*
  • Ethnicity*

  • Education

  • Please select all degrees that you have received*
  • DU student/employee*
  • Currently employed?*

  • Please enter the address of your current practice site into the links below to check if you are currently working in a rural or medically underserved area (MUA);  if you are not currently practicing, please enter your home address.

    Rural area finder (by address)

    MUA finder (by address)

  • Practicing in rural area*
  • Practicing in MUA*

  • Please enter the address of your current home address into the links below to check if you are currently living in a rural or medically underserved area (MUA).

    Rural area finder (by address)

    MUA finder (by address)

  • Living in rural area*
  • Living in MUA*
  • Format: (000) 000-0000.
  • 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 want to work in a pediatric SANE program?*
  • Do you currently have an operating pediatric SANE program in your area?*
  • Is there interest in starting a SANE program in your area?*
  • Do you have a Multidisciplinary Team (MDT) or Child Advocacy Center program in your area?*
  • Is there interest in starting a SART/MDT program in your area?*
  • Are you currently working to develop a SART/MDT program?*
  • Which of the following describes your practice site?*
  • If not working in a CAC, is your facility associated with a CAC? *
  • If working in an outpatient setting, is your facility dedicated to non-acute pediatric cases? *
  • Have you completed an adult/adolescent SANE didactic course?*
  • If yes, when did you complete your adult/adolescent SANE didactic course?
     - -
  • 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?*
  • If accepted into the program, are you willing to commit to stay in communication with program staff regarding updates on current practicing status, clinical hours logged towards SANE certification, and changes to contact information through to successful completion of the IAFN SANE exam?*
  • After completing this entire program, do you plan to take the International Association of Forensic Nurses (IAFN) Pediatric SANE certification exam? (This is the final step in becoming certified and in the grant program. Pediatric SANE exam registration fees may be reimbursed by the grant.)*
  • Will your current employer/home institution provide financial coverage for the online course fee?*
  • Signature Date*
     - -
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