ࡱ> \^[ 6bjbj>> @TTL $$gggggTS,4j($&&&&&&W~&gh"&ggpgg$$P1 k0w "w w g$&&w $ -:  Committee Biographical Data Form Please complete this form as fully as possible, preferably typed. It helps if you are brief and do not use abbreviations. The information is used by the Committee on Qualifications and Board of Directors in making appointments and fulfilling ONAs commitment to equal opportunity and affirmative action. Preferred form of Address: Ms. Miss Mrs. Mr. Dr. Other______________ Name_______________________________________________________ Degrees__________________________ Address_______________________________________________________________________________________ City_____________________________________________ State__________________ Zip__________________ Home Phone_(_______)___________________________ Home Fax_(_______)___________________________ Home Email_____________________________________ Cell Phone____________________________________ Employer Name_________________________________________________________________________________ Position/Title____________________________________________________________________________________ Employer Address_______________________________________________________________________________ Work Phone_(_______)____________________________ Work Fax_(_______)____________________________ Work Email______________________________________ Preferred Phone: Home Work Best Day/Time to Call__________________________________ am pm Preferred Mailing Address: Home Work ONA Identification Number________________________ ONA District_____________________________________ Offices, appointments or activities you ve held within your district, ONA or ANA (include years): ______________________________________________________________________________________________ Are you a member of an ONA Bargaining Unit? No Yes-Unit________________________________________ Political Party: Republican Democrat Independent None Indicate, in order of priority, which committees, etc. that you are interested in (#1 represents the highest interest): Note: You must be an ONA member to serve on an ONA committee. ONA ___Awards ___Bylaws ___Finance ___Health Policy Council ___Legislative Liaison ___ONSA Liaison ___Practice Council ___Continuing Education Approver Council ___Reference ___ONR Committee ___Environmental Caucus ONF ___ONF Board of Directors ___Research ___Scholarships Other ___ANA/ANCC Appointments ___Ohio Board of Nursing ___Government Appointments ___ONA Board of Directors * ___Nominating * ___Willing to serve in any capacity * Elected Positions Interests you have that are not indicated in the above lists:________________________________________________ (over) If you are interested in serving on the Continuing Education Approver Council, please provide the following information: Highest level of education completed (minimum of BSN required):_________________________________________ Which have you submitted for ONA approval? Individual CE Activities Provider Application LPN IV Course None Are you involved in a facility that has ONA providership for CE? No Yes What is your involvement?_________ ____________________________________________________________$%&W X Y    " $ 4 6 D F T V ~ @ B D   e f g * + , fhjľľľľľľľľľľľľľ h CJh CJOJPJQJ^J h CJ h CJ h 6CJ h 6CJ h 6CJ h CJ h CJh jhlhCUmHnHuC%&X Y B D   f g + , hj$a$$a$TV&(89:>HR]v &d 1$P $a$RTV$&(JL~789:=>GHQR\]uv01=>MNOUVƿܹܴ h 5 hCCJ h 6CJh 56CJh 56CJh h CJ h CJh h CJh CJOJPJQJ^JG1>NOV   {|$$a$$da$$a$ h^h`V    z|fh:<ln&(46*D*F*H***++++D+F+H+\+^+`+x+z+|++++++++++ h >*CJUh CJOJPJQJ^Jh 56CJ h CJh h 6CJ h 6CJ h CJ h CJJghF*H*+++F+^+z+++++,",@,V,,,$a$$ a$__________________________________ If you are interested in serving on the Practice Council, please check your major clinical interest: Practice/Administration Community Gerontology Parent/Child Med/Surg Psych/Mental Health Education Community Gerontology Parent/Child Med/Surg Psych/Mental Health Research Community Gerontology Parent/Child Med/Surg Psych/Mental Health Are you willing to review and collaborate on projects electronically? ____Yes _____No Other information you would like to share that would help the Committee on Qualifications and Board of Directors in considering your appointment: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Questions? Contact Rachel Wolfe at (614) 448-1043 or  HYPERLINK "mailto:rwolfe@ohnurses.org" rwolfe@ohnurses.org Mail form to: Ohio Nurses Association, 4000 East Main Street, Columbus, Ohio 43213-2983 or fax to (614)-237-6081. ONA is an Equal Opportunity and Affirmative Action Organization  I wish to have my name considered for appointment. 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