SANE Fellows Application July 2024

Before applying for the SANE fellowship, please review the following requirements and their dates:

All times are in Mountain Standard Time

SANE Fellowship Orientation: September 9th, 2024 6:00 pm - 7:30 pm MST
Bias and Mental Health in SANE Training: September 30, 2024 5:30 pm - 7:30 pm MST
Resiliency and Retention Workshops: Monday 6:00 pm - 7:00 pm MST
October 14th, 2024
November 4th, 2024
December 9th, 2024
January 6th, 2025
February 3rd, 2025

* For states without their own clinical skills lab, please make sure you can attend ONE of the offerings in Idaho (DVSAC):
During your interview and acceptance, you will select the dates you will attend with your interviewer

September 20 & 21, 2024
November 8 & 9, 2024
November 15 & 16, 2024
December 6 & 7, 2024

If you have any further questions, please contact Cheynna Naito at Cheynna@coloradonursingcenter.org

Name Name First Last
Phone Number Phone Number - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address
Current Employer
What state are you applying for your SANE training in?

What state are you applying for your SANE training in? Colorado Idaho New Mexico Washington Wyoming
Current education level

Current education level ADN BSN MSN PHD DNP Other (please specify) Other (please specify)
What best describes your Primary Discipline/Specialty

What best describes your Primary Discipline/Specialty Advanced Practice Nursing Clinical Nurse Leader (CNL) Clinical Nurse Specialist (CNS) Community Health Nursing Forensics Nurse Administrator Nurse Anesthetist Nurse Educator Nurse Midwife Nurse Practitioner (NP) Nurse Informatics Public Health Nurse Registered Nurse (RN)
Initial Date of nursing licensure (Month/Year)
What is your employment location setting?

What is your employment location setting? Medically underserved communities National Health Service Corp (NHSC-Approved Site) Primary care setting Rural Area None of the above N/A
What is your current employment status?

What is your current employment status? Full-time Part-time On leave of absence
Please select the option that best describes the your place of employment from the list below:
If other, please specify below:
Upon completion do you plan to serve a rural or an underserved area?

Upon completion do you plan to serve a rural or an underserved area? Yes No
Are you interested in becoming nationally certified as a SANE under IAFN?

Are you interested in becoming nationally certified as a SANE under IAFN? Yes No
Do you have 2 years of unrestricted RN licensure experience?

Do you have 2 years of unrestricted RN licensure experience? Yes No