TANNA
Member Management
TANZANIA NURSES ASSOCIATION
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Personal Information
First Name
*
Middle Name
Last Name
*
Sex / Gender (disability record)
Male
Female
Other
Prefer not to say
Date of Birth
Age
Member ID Number (disability)
Phone
Email
Region
District
Branch
County / Ward
Employment & Professional
Workplace / Facility
Facility Type
Hospital
Health Centre
Dispensary
School of Nursing
Ministry
NGO
Private
Other
Employment Status
-- Select --
Employed (Full-time)
Employed (Part-time)
Self-employed
Unemployed (Looking)
Intern
Volunteer
Retired
Other
Professional Cadre
TANNA Membership Status
Active
Inactive
Retired
Suspended
Pending
Membership Join Date
Membership Expiry Date
Status (members)
Active
Inactive
Disability Information
Disability Status
No
Yes
Primary Disability Type
Disability Type (Check all that apply)
Physical
Visual
Hearing
Speech
Psychosocial
Multiple
Other Disability Type
Disability Description / Details
Assistive Devices
Devices (Check all that apply)
Wheelchair
Walking Aid
Hearing Aid
Visual Aid
Communication Device
Other Assistive Device
Assistive Devices Notes
Employment Challenges
Challenges (Check all that apply)
Promotion
Accommodation
Communication
Stigma
Lack of Assistive Tech
None
Other Challenge
Employment Challenges Notes
Emergency Contact
Contact Name
Relationship
Phone
Alternative Phone
Email
Additional Emergency Contacts
Preferred Communication
Methods (Check all that apply)
SMS
Email
Phone Call
WhatsApp
Other Communication
Notes
Leadership & Workplace Barriers
Participates in TANNA Leadership
No
Yes
Leadership Position
Reports Workplace Barriers
No
Yes
Barrier Description
Additional Information
Details
Additional Notes
Record Active?
Yes
No
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