The Journal of the New York State Nurses Association, Vol. 44, No.1
Answer Sheet Please print legibly and verify that all information is correct. First Name:
MI:
Last Name:
State:
Zip Code:
Street Address: City: Daytime Phone Number (include area code): E-mail: Profession:
Currently Licensed in NY state? Y / N (circle one)
NYSNA Member # (if applicable):
License #:
License State:
ACTIVITY FEE: Free for NYSNA members/$10 non-members PAYMENT METHOD ■ Check—payable to New York State Nurses Association (please include “Journal CE” and your CE code R1352P on your check). Credit card:
■ Mastercard
■ Visa
■ Discover
■ American Express
Card Number: Name:
Expiration Date: Signature:
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CVV# Date:
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The contact hours for this program will be offered until September 19, 2017. Please print your answers in the spaces provided below. There is only one answer for each question.
Psychosocial Needs of Cancer Patients living in the Adirondacks: A Needs Assessment 1._________ 2._________ 3._________ 4._________ 5._________
6. _________ 7. _________ 8. _________ 9. _________ 10. ________
Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, NY, NY 10001 Or fax to: 212-785-0429
Journal of the New York State Nurses Association, Volume 44, Number 1
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