Please complete this contact information and survey form. This information will be held in the strictest of confidence and will not be sold or used for any other purpose other than official ENA business. 

Note: If you are in a leadership position, you will be asked to complete this form on a yearly basis. 

Name *
Name
Please list all of your credentials here including degrees earned, licensure, state designations, national certifications, awards and honors, other recognitions
Please note your place of primary employment. Please list the official name of the facility or organization.
What shift to you typically work at your primary employer? *
We ask this question so we do not attempt to contact you while you are sleeping.
What department to you work or report to?
Please list your official title at your primary employer (Staff Nurse, Charge Nurse, Trauma Program Manger, ED Educator, etc.)
Best Contact Number *
Best Contact Number
Please provide your best contact number should it be needed.
When to reach you
Best time to reach you *
Best time to reach you
The best time to reach you is between the hours of:
and
Best day(s) of the week to reach you *
Please note the best days of the week to get in touch with you via phone if needed. (Choose all that apply)
I will upload a current picture to be placed on the website as applicable. *
Please tell us the name your picture is saved under. For example, if your picture is named Marley.Sherri.jpeg, then simply enter Marely.Sherri.jpeg below.