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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