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Pre-Enrollment Form for Sexual Assault Nurse Examiner (SANE) Program
On behalf of the University of South Alabama College of Nursing (USA CON) Advanced Nursing Education Sexual Assault Nurse Examiner (SANE) project, we are privileged to invite your participation in one of the educational programs currently supported by a $1.1 million grant funded by the Health Resources and Services Administration (HRSA) aimed at increasing education and training of RNs to become SANEs.

Please answer all questions to the best of your ability. If there is a question that does not apply to you, please enter "N/A". Thank you so much for your interest in this program.
Email *
Last name *
First name *
Middle Name *
Maiden name/other last name *
Email address *
Phone number *
Other email address and/or phone number *
Mailing address (street number, street name, and, if applicable, apartment/unit number) or PO box *
Mailing address (city) *
Mailing address (state) *
Mailing address (zip code) *
Date of birth *
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Gender *
Race *
Ethnicity *
According to the Health Resources and Services Administration (HRSA), “environmentally disadvantaged” means “an individual’s environment inhibited him/her from obtaining the knowledge, skills, and abilities to enroll in and graduate from a health professions school.” Do you consider yourself to be environmentally disadvantaged? *
According to HRSA, “economically disadvantaged” means “an individual from a family with an annual income below a level based on the low-income thresholds, according to family size established by the U.S. Census Bureau....A family is a group of two or more individuals.” Do you consider yourself to be economically disadvantaged? *
According to HRSA, “educationally disadvantaged” means “an individual who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program.” Do you consider yourself to be educationally disadvantaged? *
According to HRSA, “rural” means “a geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as being considered rural.” Do you consider yourself to have a rural residential background (where you have an established residence)? *
According to HRSA, a “veteran” is “any person who served in one of the seven uniformed services of the United States. The seven uniformed services include: The United States Army, Navy, Air Force, Marines, Coast Guard, Public Health Service, and National Oceanic & Atmospheric Administration Commissioned Officers Corps.” Are you a veteran? *
Category of enrollment *
What is the highest degree in nursing that you currently hold at the time of this application? *
Do you hold a degree in another field? If so, please list the degree and the field. *
If you are currently enrolled in a graduate nursing program at the University of South Alabama (USA), please select your specialty. *
In what month and year did you receive your original RN license? *
NPI Number *
A SANE must have two years of experience and hold an unrestricted license. Have you ever received discipline on your RN or APRN license in any state? *
Are you currently being investigated for an RN or APRN licensure matter? *
Are you currently serving in a non-disciplinary program? *
Have you worked in any of the following areas?  Please check all that apply. *
Required
Please select all national certifications you currently hold at the time of this application (completed training and passed certification exam). *
Required
Please indicate any specialty area or population to which your above certification(s) apply (e.g., Family Nurse Practitioner, Certified Diabetes Educator, etc.) If you hold more than one, please separate each by a comma. *
Have you ever received SANE training approved by the International Association of Forensic Nurses (IAFN)? *
If you have received IAFN-approved SANE training, please indicate the specialty area/population and the date on which the training was completed.   *
The Advanced Nursing Education Sexual Assault Nurse Examiner (SANE) project offers several training opportunities. Please select all of the below opportunities in which you would be interested in participating. *
Required
Please select all of the below opportunities in which you have participated. *
Required
In what setting do you practice as a SANE? *
For how many clinical hours have your worked as a SANE between 07/01/2020 - 6/30/2021?
How many patients patient encounters have you had as a SANE between 07/01/2020 - 6/30/2021?
Did you receive training in telehealth between 07/01/2020 - 6/30/2021? *
How many telehealth contact hours did you have between 07/01/2020 - 6/30/2021? *
How many telehealth patient encounters did you have between 07/01/2020 - 6/30/2021? *
Vicarious Trauma (VT) is a special challenge for SANEs. In addition, those who have experienced personal trauma may be at higher risk. Answering the following question does not affect your acceptance into the program. It may assist faculty in sharing resources and planning programming better. Have you experienced sexual assault personally?
Clear selection
If you have experienced sexual assault personally, would you like to be contacted by someone specialized in vicarious trauma?
Clear selection
Thank you again for completing this application. You will be contacted soon to further discuss the program.
Nurses currently serving sexual assault victims or those from underserved areas may be eligible for a student stipend on a first come/first served basis. Note that submission of this application does not guarantee your enrollment in this program nor the awarding of a stipend. You will be notified upon acceptance into the program of your eligibility for consideration of a stipend.
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