Ohio Nurses Association
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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 ONA’s commitment to equal opportunity and affirmative action.
Preferred form of Address: ϒ Ms. ϒ Miss ϒ Mrs. ϒ Mr. ϒ Dr. ϒ 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: ϒ Home ϒ Work Best Day/Time to Call__________________________________ ϒ am ϒ pm
Preferred Mailing Address: ϒ Home ϒ 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? ϒ No ϒ Yes-Unit________________________________________
Political Party: ϒ Republican ϒ Democrat ϒ Independent ϒ 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?
ϒ Individual CE Activities ϒ Provider Application ϒ LPN IV Course ϒ None
Are you involved in a facility that has ONA providership for CE? ϒ No ϒ Yes–What is your involvement?_________
______________________________________________________________________________________________
If you are interested in serving on the Practice Council, please check your major clinical interest:
Practice/Administration
ϒ Community
ϒ Gerontology
ϒ Parent/Child
ϒ Med/Surg
ϒ Psych/Mental Health
Education
ϒ Community
ϒ Gerontology
ϒ Parent/Child
ϒ Med/Surg
ϒ Psych/Mental Health
Research
ϒ Community
ϒ Gerontology
ϒ Parent/Child
ϒ Med/Surg
ϒ 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 rwolfe@
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. If appointed, I will abide by the ONA Bylaws, the ANA Code of Ethics for Nurses and the policies and actions of the ONA House of Delegates and Board of Directors.
_______________________________________ (_____)__________________ __________________
Signature Daytime Phone Date
3/31/15
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