Thank you for your interest in volunteering as an LNCC program Item Writer. The information collected in the following questionnaire will assist the American Legal Nurse Consultant Certification Board (ALNCCB) to know what topics/issues you are interested in as well as your areas of skill and expertise. Please complete the following areas appropriately.

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* 1. Name

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* 3. Phone Number

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* 4. Address

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* 5. Employer Name

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* 6. Current Position

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* 7. Number of years as a Registered Nurse

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* 8. Are you certified as an LNCC?

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* 9. List any additional certifications you hold.

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* 10. Have you served as an ALNCCB Item Writer in the past?

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* 11. Have you served as a volunteer for ALNCCB in the past?

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* 12. Please indicate the highest level of nursing education you have completed:

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* 13. Indicate your areas of subject matter expertise as a Legal Nurse Consultant and number of years experience in these areas:

  < 5 years > 5 years
Medical malpractice
Personal injury
Product liability
Long term care litigation
Workers' Compensation
Risk management
Life Care planning
Toxic Tort
Regulatory compliance
Medicare set-aside

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* 14. Please provide a brief statement describing your leadership experience and areas of professional expertise which contribute to your qualifications for this volunteer position:

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