• Online SANE Training Application

  • Contact Information
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Employment Information
  • Format: (000) 000-0000.
  • What type of agency do you work for? (Check all that apply)
  • Do you want to work in a SANE program?*
  • Education
  • Highest Level of Education*
  • Demographics
  • Gender*
  • Citizenship*
  • Marital Status*
  • Race*
  • Ethnicity*
  • Computer Skills
  • Online courses require some basic computer skills. Please tell us what functions you are comfortable executing on your computer. (Check all that apply)
     
  • Internet
  • Email
  • Files
  • Group Communication Tools
  • Software (Please indicate program and skill level for each application)
  • Is this your first online course?*
  • Have you taken previous SANE training (prior to the one at Duquesne University)?*
  • Preceptor
  • Do you have access to a mentor (nurse practitioner, midwife, SANE, MD, etc.) to provide a preceptored experience for you to learn speculum insertion?*
  • Would you like assistance with identifying a preceptor and setting up a clinical experience to learn speculum insertion?
  • After completing this course and preceptored experience, do you plan to take the IAFN certification exam?*
  • SANE Program
  • Do you currently have an operating SANE program in your area?*
  • Is there interest in starting a SANE program in your area?
  • Are you currently working to develop a SANE program?
  • SART Program
  • Do you have a SART program in your area?*
  • Is there interest in starting a SART program in your area?
  • Are you currently working to develop a SART program?
  • Copyright Information
  • Signature Date*
     - -
  • Payment Your registration is not complete until we receive your payment. You will receive instructions in an email upon submitting this form. Please let us know your anticipated form of payment:
     
  • Payment Method
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