Name District

Years in School Nursing MA location (West, Central, North, South)

Need Mandated Screening Training;
Vision Y N | Hearing Y N | Scoliosis Y N

Please rate all subjects of interest on a scale of 1 (low level of interest) to 5 (high level of interest).

Mental Health Issues
1 2 3 4 5

Legal Issues
1 2 3 4 5

Physical Assessment
1 2 3 4 5

Asthma and Allergy
1 2 3 4 5

Substance/Chemical Abuse
1 2 3 4 5

Pharmacology Updates
1 2 3 4 5

Seizures/Epilepsy
1 2 3 4 5

School Nurse Leadership
1 2 3 4 5

Research and Publication
1 2 3 4 5

Emergency Preparedness
1 2 3 4 5

Orthopedic injuries
1 2 3 4 5

Tobacco cessation
1 2 3 4 5

PDD/Autism
1 2 3 4 5

Multi-cultural issues
1 2 3 4 5

OTHER

Preferred Days for Conferences (Choose 3)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Preferred Months for Conferences (Choose 5)
Jan
Feb
March
April
May
June
July
August
Sept
Oct
Nov
Dec

Preferred Times for Conferences (Check all that apply)
All day (9-3)
AM only (9-12)
PM only (12-3)
Afternoon (4-6)
Saturday (9-1)

Preferred Locations for Conferences (Choose 3)
Burlington
Boston
Auburn
Marlboro
Plymouth
Northampton