American Psychological Association
Task Force on Strategies to Eradicate Racism, Discrimination, & HateNomination MatrixOnce completed, please send this to Brad Pabian (bpabian@), Director of Governance, APA Public Interest, and Tiffany Sleek (tsleek@), Program Coordinator, by August 1, 2020.Nominee Name: (full name here)Nominee Contact Information: (email address)Nominated By: (self or other)1Please remember to provide/attach an up to date CV or resume2Supporting statement of qualifications (500 words or fewer)(Please type/include your statement here)3Please complete the checklist belowNominee Subject Matter ExpertiseCheck all that applyNotesStructural or Institutional Racism ?Please specify institutional expertise here (i.e. Education, Medicine, Law Enforcement, etc…)Interpersonal or Internalized Racism?Please specify expertise here (Implicit Bias, Stereotyping, Stigma, etc…)Historical or Sociological Analysis of Racism?Anti-racism training, program evaluation, curriculum design and delivery, or train-the-trainer models?Other Desired ExpertiseCheck all that applyNotesFormer APA or other Task Force Experience?Please specify hereDiversity of Work SettingCheck all that applyNotesPsychologist?Please identify specialization hereNon-Psychologist?Please identify discipline hereEducation (K-12 or Higher Ed)?Science or Research?Independent Practice?Non-Profit ?Other (Please identify in notes)?Diversity of Career StageNotesEarly Career?Mid-Career?Late-Career?Demographic DiversityCheck all that applyNotesRace/Ethnicity ?Please specify hereLGBT?Please specify hereDisability?Please specify hereReligion?Please specify hereOther?Please specify hereAdditional Considerations or Other Types of DiversityCheck all that applyNotesGeographical Diversity?Please provide state/province/country of residence here ................
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