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FACE DATA SHEET

NAME: ______________________________ AGE:_____ GENDER: M__ F __

NO. OF NURSING EXPERIENCE:

0-11 MONTHS

1-2 YEARS

3-4 YEARS

5 YEARS UP

AREA OF EXPOSURE/ ASSIGNMENT:

HOSPITAL

COMMUNITY

EDUCATION

PRIVATE DUTY

OCCUPATIONAL HEALTH

OTHERS (pls. specify) ______________

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