OPTN/UNOS

Board of Directors Candidate Biography Form

Please type or print your responses.

Nominations without a completed biography form will not be considered. No CVs please

Please indicate position of interest

Vice President ____
Treasurer ____
Minority Transplant Professional Representative ____
Patient and Donor Affairs Representative ____

Person Making Nomination

Name: ______Affiliation: ______Phone or Email: ______
1. Last Name First MI 2. Date of Birth
/ /
  1. Professional degree(s) you would like to have listed after your name.
Please place a number after each to indicate the order in which they should appear.
M.D. ___ J.D.___ Ph.D. ___ B.A. ___B.S. ___ B.S.N. ___ M.S. ___ M.S.N. ___
M.S.H.A. ___M.H.A. ___ M.P.A. ___ M.P.H. ___ M.A. ___ M.B.A. ___ RN ___
CPTC ___ CCTC ___ Other: ______
4. Address where you wish to receive mail from UNOS:
4a. Name of Administrative Assistant:
5. Telephone Number(s):
Office:
Mobile: / 6. Fax Number(s): / 7. E-mail Address(es):
5a. Administrative Assist: / 6a. Administrative Assist: / 7a. Administrative Assist:
8. Sex:
M ___F ___ / 9. Ethnicity:
10. Your present title and the name and address of your employer:
11. Professional degree(s) you have obtained:
Date Degree Institution
12. Please list any performance improvement techniques routinely used by your
transplant center to improve transplant outcomes.
13. Have you participated in the Organ Donation and/or the Yes __ No __
Transplantation Breakthrough Collaboratives?
If yes, please provide a brief summary of how your participation assisted your institution’s efforts to increase the number of deceased donor transplants, increase organ donors (DCD & Non-DCD, and increase the number of organs transplanted per donor (DCD & Non-DCD).
14. Have you been nominated as a Patient Representative? Yes __ No __
If no, please go to item 15.
A. Are you a recipient of an organ transplant? Yes __ No __
If no, please go to item B. If yes, please state the
organ type(s) and date(s) of the transplant(s).
B. Are you related to a transplant recipient? Yes __ No __
If no, please go to item 15. If yes, please state the
organ type(s) and date(s) of the transplant(s), and
your relationship to the recipient.
15. Have you been nominated as a Living Donor Representative? Yes __ No __
If no, please go to item 16. If yes, please state the date of
the donation and your relationship to the donor.
16. Have you been nominated as a Donor Family Representative? Yes __ No __
If no, please go to item 17. If yes, please state the date of
the donation and your relationship to the donor.
17. Please list all past and present OPTN/UNOS responsibilities (i.e., Committee
Chairman, Committee Member, etc.), in chronological order. Also, please
list any particular UNOS projects in which you have been involved. If additional
space is needed, please attach additional page(s).
Date(s) Responsibility or Project
18. Please list all past and present non-OPTN/UNOS offices you have held that
pertain to organ donation or transplantation, in chronological order, and provide
a briefdescription of your involvement for each. If additional space is
needed, please attach additional page(s).
Date(s) Office
19. Please list any additional accomplishments you think might assist the
Nominating Committee in evaluating your candidacy. If additional space is
needed, please attach additional page(s).
Date(s) Accomplishment

This form should be completed by the candidate and e-mailedto:

Karen Riceat . E-mail is preferred, but faxes are also accepted at (804) 782-4816.

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UNOS 2012