AANP Network for Research
Membership Application

The AANP Network for Research (AANPNR) is a primary care, practice-based research network. Membership is open to all primary care NPs who are members of AANP. If you are interested in joining the AANPNR, please complete this form with as much detail as possible.

Personal Information

Last Name:
First Name:
Home Street Address:
Phone:
City:
State:
ZIP:
Date of Birth:
   
Email:

NP Experience

Years of NP experience:
Highest degree earned:



Certification:



Specialty (mark all that apply):







Practice Site Information

Name of Practice Site:
Street Address: Phone:

City:
State:
ZIP:
Fax:
Average number of hours you practice in this setting per week:  
Average number of patients you see in this setting per hour:  
Average number of patients you see in this setting per week:  
Average number of patients seen in the entire practice on a daily basis (includes other providers):  
Does your practice have an electronic medical records system?  
Does your site have a local IRB/privacy board that reviews proposed projects?

Research Experience & Interests

Please describe your experience in performing/participating in research, highlighting primary care research as applicable.  Prior experience is not a requirement of membership.
Please describe your main research interests here.

Note: At times a user's browser is incompatible with AANP survey submission. You may want to print out a completed application before pressing submit in order to save your answers. If you receive an error message, email your application and the error message to Kevin Traylor, Research Coordinator at ktraylor@aanp.org. We appreciate your assistance in improving our process.