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: Registered Nurse
INSTRUCTIONS: Please PRINT or TYPE and complete this entire form. Please 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.
 NOMINATION TO :
ANA AUDIT COMMITTEE
(COMMITTEE NAME/OTHER APPOINTMENT)
NAME
Title
Name
NAME
Ms.
Miss
Mr.
Dr.
Other (specify:
)
(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
Gender
Race/Ethnic Group
(Indication of “race/ethnic group”, which is used
for affirmative action purposes, is optional.)
DEMOGRAPHICS
Female
Male
American Indian/Alaska Native
Black/African American
Native Hawaiian/Other Pacific Islander
White (non-Hispanic)
Asian
Hispanic/Latino
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
Administration/Management
Anesthesia
Cardiology
Clinical Research
Community/Public Health
Critical Care
Education
Emergency Room
Ethics
Family Nursing
General Practice
Gerontological Nurse
HIV
Informatics
Long Term Care
Neonatal
Neurology
OB/GYN
Occupational Health
Oncology
Operating Room
Orthopedics
Pediatrics
Perinatal
Post Anesthesia
Primary Care
Psychiatry/Mental Hlth
Rehabilitation
Substance Abuse
Women’s Health
Other
Specify:
AMERICAN NURSES ASSOCIATION
Biographical Data Form for Appointment: Registered Nurse
Page 2 of 4
EDUCATION (Begin with highest degree earned)
DEGREE/DIPLOMA
AREA OF STUDY
YEAR
EDUCATIONAL INSTITUTION
1.
2.
3.
4.
CERTIFICATION AND 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
1.
FROM:
TO:
2.
FROM:
TO:
3.
FROM:
TO:
4.
FROM:
TO:
EMPLOYER
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
1.
2.
TERM
FROM:
FROM:
TO:
TO:
TERM
FROM:
FROM:
TO:
TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY
1.
2.
Nominee’s Name:
Date:
AMERICAN NURSES ASSOCIATION
Biographical Data Form for Appointment
Page 3 of 4
OFFICES/APPOINTMENTS/ACTIVITIES (continued)
CONSTITUENT MEMBER ASSOCIATION
(List up to TWO offices/appointments/activities. Give complete title.)
♦♦♦♦ PRESENT ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY
1.
2.
TERM
FROM:
FROM:
TO:
TO:
TERM
FROM:
FROM:
TO:
TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY
1.
2.
DISTRICT/REGIONAL NURSES ASSOCIATION
(List up to TWO offices/appointments/activities. Give complete title.)
♦♦♦♦ PRESENT ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY
1.
2.
TERM
FROM:
FROM:
TO:
TO:
TERM
FROM:
FROM:
TO:
TO:
♦♦♦♦ PAST ♦♦♦♦
OFFICE/APPOINTMENT/ACTIVITY
1.
2.
ADDITIONAL INFORMATION
Activities with other associations (nursing specialty organizations, national associations, include offices held):
Involvement in community, state, or international/national health care concerns:
Other information you would like to provide:
Nominee’s Name:
Date:
AMERICAN NURSES ASSOCIATION
Biographical Data Form for Appointment
Page 4 of 4
If not appointed, I would agree to be considered for the following appointive positions:
APPOINTIVE POSITION TO
American Nurses Credentialing
Center Board of Directors
American Nurses Foundation Board
of Trustees
ANA Consultant to the NSNA Nominee
YES
(√)
NO
(√)
YES
(√)
APPOINTIVE POSITION TO
Nursing Information Data Set Evaluation
Center Committee
Reference Committee
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)
ICN Board of Directors – US
Candidate
NO
(√)
Subcommittee on Hall of Fame Award
If appointed I agree to serve. __________________________________________________________
(Signature)
(Print) Nominee’s Name:
(Date)
Date: