Bioterrorism FAQ Signup
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First Name:
*
Middle Name:
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Last Name:
*
Basic Nursing Education:
*
AD
Diploma
BS
Other
Not a Nurse
Highest Nursing Degree:
*
AD
Diploma
BS
Masters in Nursing
Masters in Other Field
Doctorate
Other
Not a Nurse
Address:
City:
State:
Zip:
Work Phone:
Email:
Workplace or Practice Setting:
Other
Health Department
Institution of Higher Education
Hospital
Health Center
School
If other, please specify...:
Job Title/Position:
Specialty:
Do you provide direct patient care?:
Yes, Full-time
Yes, Part-time
No
Retired
Gender:
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Male
Female
Age Group:
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18-34
35-49
50-64
>=65
Race/Ethnicity:
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
In regard to a bioterrorist event occurring in or near your workplace, are you:
*
very concerned
concerned
neither concerned or unconcerned
unconcerned
very unconcerned
How prepared do you feel personally regarding your role at work in any bioterrorist event?:
*
very prepared
moderately prepared
a little prepared
somewhat prepared
moderately unprepared
very unprepared
Overall, how would you rate your knowledge about emerging infectious diseases on a scale from 1 to 10?:
*
1
2
3
4
5
6
7
8
9
10
With ten being excellent and 1 being very poor
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