Priority Application for Sexual Assault Nurse Examiner Program

First Name:

Middle Name:

Last Name:

Preferred Name:

Other Names:

Employer Name:

Unit:

Hofstra ID (9 Digits) - If Applicable:

Date of Birth:

Mailing Address:

City/Town:

State/Province:

Zip:

Country:

Email Address:

Telephone Number (Format: 516-555-1234)

Cellular Home

I give permission to Hofstra University to send me important updates via text messaging. (Standard messaging charges apply.)

Sex: Male Female

Citizenship:
U.S. Citizen or U.S. National U.S. Dual Citizen U.S. Permanent Resident U.S. Refugee or Asylee Other (Non-U.S.)

Country of Citizenship:

Country of Birth:

Do you currently hold a valid U.S. visa? (If no and you intend to apply for a U.S. visa, please indicate type of visa.): Yes No

Visa Type:

Term of Entry:
October 2024: LIJ Emergency Department Spring 2025

Please accept this application for admission to: Sexual Assault Nurse Examiner Certificate Program.

Prior Degree (ie: BSN):

Current Area of Nursing Practice (i.e., ED, L&D, Med-Surg):

Additional Information
Have you ever been found responsible for a disciplinary violation at any college or university (or the international equivalent), whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution, or do you have any charges of disciplinary violations pending against you?
Yes No

Have you ever been adjudicated guilty or convicted of a misdemeanor or felony, or do you have any charges of a misdemeanor or felony pending against you? (Note that you are not required to answer "Yes" to this question or provide an explanation if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.)
Yes No

Are you Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)?
Yes No

Select one or more of the following races:
American Indian or Alaska Native    Asian    Black or African American    Native Hawaiian or Other Pacific Islander    White

Please indicate your U.S. military service status (if applicable):
U.S. Military Active Duty U.S. Reserves or National Guard No U.S. Military Dependent/Spouse/Widow(er)

Prior Institution:

Date of Degree Conferral:

Program/Degree Obtained (i.e., Literary Studies / MSEd):

GPA:

Prior Institution:

Date of Degree Conferral:

Program/Degree Obtained (i.e., Literary Studies / MSEd):

GPA:

Prior Institution:

Date of Degree Conferral:

Program/Degree Obtained (i.e., Literary Studies / MSEd):

GPA:

• A letter of recommendation from a current manager or service line leader is required and should be submitted with the application.
• Each applicant is required to submit a 1000 word essay discussing your interest in becoming a SANE with this application.
• A background check is to be completed by the applicant prior to December 1, 2021. Instructions for completing this will be sent upon acceptance to the program.

For specific admission and degree requirements, consult the official Hofstra University Graduate Studies Bulletin at bulletin.hofstra.edu.
The Office of Graduate Admission reserves the right to enforce these requirements and all other stipulations set forth by the various academic departments.

Once physically signed below, please return this form to the Department of Nursing by email to sgnpa@hofstra.edu or by mail to 160 Hofstra University, 400 Shapiro Family Hall Hempstead, NY 11549.
I understand the regulations and stipulations set forth above and have read and acknowledge them as necessary conditions of enrollment.
I certify that the information I provided above is accurate and complete.

Signature (Enter First and Last Name):

Date:

NONDISCRIMINATION POLICY: Hofstra University is committed to extending equal opportunity to all qualified individuals without regard to race, color, religion, sex, sexual orientation, gender identity or expression, age, national or ethnic origin, physical or mental disability, marital or veteran status in employment and in the conduct and operation of Hofstra University's educational programs and activities, including admissions, scholarship and loan programs, and athletic and other school-administered programs. This statement of nondiscrimination is in compliance with Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act Amendments Act, the Age Discrimination Act, and other applicable federal, state and local laws and regulations relating to nondiscrimination (“Equal Opportunity Laws”). The Equal Rights and Opportunity Officer is the University's official responsible for handling inquiries regarding the nondiscrimination policies and coordinating its overall adherence to Equal Opportunity Laws. Questions or concerns regarding any of these laws or other aspects of Hofstra's Nondiscrimination Policy should be directed to the Equal Rights and Opportunity Officer at EROO@hofstra.edu, 516-463-7310, C/O Office of Legal Affairs and General Counsel, 101 Hofstra University, Hempstead, NY 11549. The University's Title IX Coordinator, who is responsible for the University's efforts to comply with and carry out responsibilities under Title IX, can be reached at TitleIXCoordinator@hofstra.edu, 516-463-5841, 214 Roosevelt Hall, Hempstead, NY 11549. For additional contacts and related policies and resources, see hofstra.edu/eoe.

CAMPUS CRIME REPORTING AND FIRE SAFETY STATISTICS: In compliance with the federal Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act and other federal law, detailed information on campus security and fire safety, including statistics, is available by accessing the Hofstra website at hofstra.edu/campussafetyreport or by contacting the Advisory Committee on Campus Safety. Crime statistics are also available at the U.S. Department of Education website at ope.ed.gov/security. The Advisory Committee on Campus Safety will provide upon request all campus crime and fire safety statistics as reported to the U.S. Department of Education. For additional information or a paper copy of the report, please call the Department of Public Safety at 516-463-6606.

HOFSTRA UNIVERSITY HARASSMENT POLICY: Hofstra's prohibition against discrimination is also addressed in Hofstra's Harassment Policy. The Harassment Policy prohibits harassment – including sexual harassment and sexual violence – based on race, color, religion, sex, sexual orientation, gender identity or expression, age, national or ethnic origin, physical or mental disability, marital or veteran status. Hofstra University is committed to professional and interpersonal respect ensuring that no individuals are subjected to harassment or discriminated against in any way on the basis of any of these protected characteristics. Harassment based on any of these protected characteristics is a form of discrimination prohibited by law and by Hofstra University's Harassment Policy. The Harassment Policy, which is available online at the link referenced below, contains complaint procedures for resolving complaints of harassment in violation of Hofstra's Harassment Policy. Harassment policy link: hofstra.edu/harassment