Biographical Data Form to be completed by CMA/IMD member.

Consideration is restricted to information provided on this form.

AMERICAN NURSES ASSOCIATION

Biographical Data Form for Appointment

ANCC BOARD OF DIRECTORS: REGISTERED NURSE NOMINEE

INSTRUCTIONS: Please PRINT or TYPE and complete this entire form. Respond clearly and succinctly, as this will be the only biographical information reviewed for consideration. Attachments will NOT be accepted. Do not use abbreviations. All personal information will be confidential within ANA. Your signature (on the last page of this form) is required. Please provide an “X” in the boxes to record your responses.

NAME / NAME
Title / Ms. Miss Mr. Dr. Other (specify: )
Name
(include credentials; the first 5 will be used on official documents)
HOME ADDRESS / HOME ADDRESS (PREFERRED CONTACT )
Street/Apt.
City: State: Zip: / City: State:Zip:
Telephone (w/ area code)
Fax Number (w/area code)
E-Mail Address
BUSINESS ADDRESS / BUSINESS ADDRESS (PREFERRED CONTACT )
Business Name
Street
City: State: Zip: / City: State:Zip:
Telephone (w/ area code)
Fax Number (w/area code)
E-Mail Address
MEMBERSHIP INFORMATION / MEMBERSHIP INFORMATION
Member of Which CMA
or (√) IMD / IMD
ANA Membership Number
DEMOGRAPHICS / DEMOGRAPHICS
Gender / Female Male
Race/Ethnic Group
(Indication of “race/ethnic group”, which is used for affirmative action purposes, is optional.) / American Indian/Alaska Native Asian
Black/African American Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White (non-Hispanic) Other (specify: )
The increased involvement of minorities and staff nurses at the national level of the association is a high priority.
Staff Nurse (√) / Yes No (A staff nurse is defined as one who spends the majority of work time in a non-supervisory, non-managerial capacity and includes one or more of the following: (1) is employed by a health care institution or agency; (2) whose primary role is a provider of direct patient care; (3) is collective bargaining eligible under applicable labor law.)
MAJOR CLINICAL, TEACHING, PRACTICE OR RESEARCH AREA (√)
Acute Care / Education / Informatics / Operating Room / Rehabilitation
Administration/Management / Emergency Room / Long Term Care / Orthopedics / Substance Abuse
Anesthesia / Ethics / Neonatal / Pediatrics / Women’s Health
Cardiology / Family Nursing / Neurology / Perinatal / Other
Clinical Research / General Practice / OB/GYN / Post Anesthesia / Specify:
Community/Public Health / Gerontological Nurse / Occupational Health / Primary Care
Critical Care / HIV / Oncology / Psychiatry/Mental Hlth

AMERICAN NURSES ASSOCIATION

Biographical Data Form for Appointment to

ANCC Board of Directors

Page 2 of 5

EDUCATION (Begin with highest degree earned)
DEGREE/DIPLOMA / AREA OF STUDY / YEAR / EDUCATIONAL INSTITUTION
1.
2.
3.
4.
CERTIFICATIONS, OTHER ACADEMIC ACHIEVEMENTS AND HONORS (describe briefly)
EMPLOYMENT
CURRENT EMPLOYER
POSITION TITLE
LENGTH OF EMPLOYMENT / FROM: / TO:
Description of current position including work setting and responsibilities:
Other significant employment positions held:
POSITION / TERM OF EMPLOYMENT / EMPLOYER
1. / FROM: / TO:
2. / FROM: / TO:
3. / FROM: / TO:
4. / FROM: / TO:
If appointed, how would you contribute to the position? Why should you be appointed?
OFFICES/APPOINTMENTS/ACTIVITIES
AMERICAN NURSES ASSOCIATION
(List up to TWO offices/appointments/activities. Give complete title.)
♦♦♦♦ PRESENT ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:

Nominee’s Name: Date:

AMERICAN NURSES ASSOCIATION

Biographical Data Form for Appointment to

ANCC Board of Directors

Page 1 of 5

OFFICES/APPOINTMENTS/ACTIVITIES (continued)
CONSTITUENT MEMBER ASSOCIATION
(List up to TWO offices/appointments/activities. Give complete title.)
♦♦♦♦ PRESENT ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:
DISTRICT/REGIONAL NURSES ASSOCIATION
(List up to TWO offices/appointments/activities. Give complete title.)
♦♦♦♦ PRESENT ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY / TERM
1. / FROM: / TO:
2. / FROM: / TO:
EXPERIENCE AND SKILLS
CREDENTIALING - Experience/ knowledge in credentialing (e.g., certification, accreditation, recognition programs):
BUSINESS - Experience/knowledge in health care business financing, general business financing, business operations, international business, marketing:
TECHNOLOGY - Experience/knowledge in technology especially with regard to online education and/or service delivery:
LEADERSHIP - Leadership experience/skills in facilities with Magnet Recognition®, nursing associations:
HEALTH CARE -Experience /knowledge – healthcare consumer, involvement in community, state, or international/national health care concerns:
OTHER - Other information you would like to provide:

Nominee’s Name: Date:

AMERICAN NURSES ASSOCIATION

Biographical Data Form for Appointment to

ANCC Board of Directors

Page 1 of 5

If not appointed, I would agree to be considered for the following appointive positions:

APPOINTIVE POSITION TO / YES
(√) / NO
(√) / APPOINTIVE POSITION TO / YES
(√) / NO
(√)
American Nurses Credentialing Center Board of Directors / NursingInformationDataSetEvaluationCenter Committee
American Nurses Foundation Board of Trustees / Reference Committee
ANA Consultant to the NSNA - Nominee / Subcommittee on Mary Mahoney Award
ANA-PAC Board of Trustees / Subcommittee on Pearl McIver Public Health Nurse Award
Audit Committee / Subcommittee on Hildegard Peplau Award
Center for Ethics & Human Rights Advisory Board / Subcommittee on Jessie M. Scott Award
Committee on Bylaws / Subcommittee on Barbara Thoman Curtis Award
Committee on Honorary Awards / Subcommittee on Shirley Titus Award
Congress on Nursing Practice & Economics / Subcommittee on Mary Ellen Patton Staff Nurse Leadership Award
Delegate Credentials Committee / Subcommittee on Luther Christman Award
Other Committees ( e.g. ad hoc, task force) / Subcommittee on Hall of Fame Award
ICN Board of Directors – US Candidate

If appointed I agree to serve. ______

(Signature)(Date)

(Print) Nominee’s Name: Date: