Part I: General Information

Transcription

1 Part I: General Information * 1. Contact Information Name Company Address Address 2 City State -- select state -- ZIP Address Work Phone (and extension) * 2. Additional Contact Information Your Title Cell Phone

2 Part II: Professional Licensure * 3. Professional Licensure Check all that apply. EMR EMT AEMT Paramedic Physician Nurse Manager/Administrator Other (please specify)

3 Part III: Your Role in EMS * 4. Please briefly describe your current primary role in EMS. 100-word limit

4 Part IV: National EMS Organization Application will be verified by the Organization supporting the appointment. * 5. Your organization N/A (submitting application as an independent SME) American Academy of Pediatrics American Ambulance Association American College of Emergency Physicians American College of Surgeons Committee on Trauma International Association of Fire Chiefs International Association of Fire Fighters International Association of Flight and Critical Care Paramedics National Association of EMS Educators National Association of EMS Physicians National Association of EMTs National Association of State EMS Officials National EMS Management Association

5 Part V: At Large Applicants You are viewing this question because you indicated you are submitting your application as an independent Subject Matter Expert. * 6. Do you understand that you will provide your best technical guidance without prejudice to your own company, organization, or employer? Yes

6 Part IV: National EMS Organization Because you are applying on behalf of an organization, you must submit a letter of support from the organization for your nomination. Please see details at end of application.

7 Part VI: Background and Experience Please complete the following or additional sheets as necessary. * 7. List previous Working Group/Committee service, including other similar organizations on which you have served. List relevant performance and research-related organizations, education, and service, including organization/committee date or years of service in related activity. * 8. State specific work experience you feel makes you a preferred candidate for this project. * 9. State the contributions, education, certification or other qualifications you offer towards the success of the Subject Matter Expert Panel.

8 Part VII: Additional Information 10. Provide any additional information as may be appropriate to assist in the evaluation of your application. Use this space to make your case for the value of your participation toward furthering the work of this expert panel.

9 Part VIII: Certification and Agreement * 11. Being a Subject Matter Expert obligates the participant to commit to be active in all work of SoPM revision development, including attendance and participation at group meetings, contribution of information, prompt reply to s requesting action, and on-time completion of assigned tasks. The undersigned agrees to abide by the policies and procedures of the SMEP and attests that the information provided in this application is true and accurate. The undersigned hereby agrees that his or her authorship contributions to the SMEP in connection with work performed as a Subject Matter Expert are considered to be works in the public domain. To the extent that the undersigned retains any rights in copyright as to such authorship contributions, the undersigned hereby grants and assigns to NASEMSO and/or NHTSA all such rights to use these works in the public domain. The undersigned understands that he or she will have no rights in any publications that use such contributions by the undersigned and certifies to the best of his or her knowledge that such contributions are not protected by the copyright of any other person or entity. Electronic Signature (Please print your name) Date

10 Additional Documents Please submit your resume via to Zoe Renfro If you are applying on behalf of an organization, you must also submit a letter of support for your nomination from the organization. Organizational applicants that do not provide a letter of support on official letterhead will be considered in the general pool of applicants for limited seats. You indicated that you are submitting your application on behalf of: {{ Q5 }} Any questions regarding this application, please contact: Kathy Robinson Dan Manz