PAC Advisory Board Application

Committee Overview

The American Academy of Audiology’s governance structure aligns the work of the organization through its councils, committees, and subcommittees.

The PAC Advisory Board works to identify key members of Congress to support based on willingness to support audiology/hearing healthcare and position on Committees of jurisdiction and supports fundraising efforts in order to contribute PAC funds to Congressional members enabling them to fight for legislation that will benefit our community and profession.

To learn more about this committee and its charges, click the link below to be taken to Academy website for more information.

https://www.audiology.org/about/committees-and-task-forces/pac-advisory-board/

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* 1. Please provide the information we can use to contact you.
Note: Please choose an e-mail you check regularly.

First and Last Name

Email Address

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* 2. What is your Academy (Member) ID number?
Volunteers must be current Academy members at the time of application and for the entirety of volunteer term, if appointed. Don't know your member ID? Email membership@audiology.org.

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* 3. What is your membership type?

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* 4. Please indicate your years of professional experience.

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* 5. Please indicate your work setting.

Questions 6-10 are optional. If you are comfortable disclosing, please select the option(s) that best reflect you. This information will be used by the Academy to continue diversity, equity, inclusion, and belonging efforts.

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* 6. Which of the following most accurately describes you? (select all that apply)

Woman

Man

Non-binary

Transgender

Intersex

Prefer not to say

Other (please specify):

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* 7. Do you identify as a part of the LGBTQIA+ community, not including as an ally?

Yes

I am not sure

Prefer not to say

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* 8. Which category/categories best describe you (select all that apply)?

American Indian or Alaskan Native (e.g., Navajo Nation, Mayan, Aztec, Traditional Government, Nome Eskimo Community)

Asian (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese)

Black, African American, or African Heritage (e.g., Ethiopian, Haitian, Jamaican, Nigerian, Somalian)

Hispanic, Latino, or Spanish Origin (e.g., Cuban, Colombian, Dominican, Mexican American, Puerto Rican, Salvadorian)

Middle Eastern or North African (e.g., Algerian, Egyptian, Lebanese, Iranian, Moroccan, Syrian)

Mixed

Unsure

Prefer not to answer

Some other race, ethnicity, or origin, please specify:

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* 9. Disability: (ADA definition of disability) The ADA defines an individual with a disability as a person who: (1) has a physical or mental impairment that substantially limits a major life activity, (2) has a record or history of a substantially limiting impairment, or (3) is regarded or perceived by an employer as having a substantially limiting impairment. Do you identify as having a disability?

Yes

I don't know

Prefer not to say

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* 10. If applicable, select which type(s) of disability you identify with:

Physical, please specify:

Sensory, please specify

Mental Health, please specify:

Other (please specify):

Prefer not to say

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* 11. Please indicate any areas in which you have experience/knowledge.

Clinical document development and methodology

Peer review of clinical practice documents

Regulatory work

Coding experience

Grassroots advocacy

Research

Grant development

Clinical education/precepting

Interprofessional practice

Credentialing

Please upload a signed Conflict of Interest form and Code of Conduct form below using the corresponding hyperlinks. These forms are required to be able to volunteer with the Academy. Reach out to Hannah Mahieu at hmahieu@audiology.org with any questions or issues uploading the forms.

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* 12. Please upload a copy of your Conflict of Interest form. The form can be filled out and signed electronically, or you may print and scan.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 13. Please upload a copy of your Code of Conduct form. The form can be filled out and signed electronically, or you may print and scan.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 14. Have you volunteered with the Academy before?

Yes

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* 15. Tell us a little bit about yourself, why you choose to volunteer, why this committee interests you, or anything else you think will strengthen your application.

PAC Advisory Board Application

Committee Overview

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* 1. Please provide the information we can use to contact you.Note: Please choose an e-mail you check regularly.

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* 2. What is your Academy (Member) ID number?Volunteers must be current Academy members at the time of application and for the entirety of volunteer term, if appointed. Don't know your member ID? Email membership@audiology.org.

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* 3. What is your membership type?

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* 4. Please indicate your years of professional experience.

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* 5. Please indicate your work setting.

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* 6. Which of the following most accurately describes you? (select all that apply)

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* 7. Do you identify as a part of the LGBTQIA+ community, not including as an ally?

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* 8. Which category/categories best describe you (select all that apply)?

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* 10. If applicable, select which type(s) of disability you identify with:

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* 11. Please indicate any areas in which you have experience/knowledge.

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* 12. Please upload a copy of your Conflict of Interest form. The form can be filled out and signed electronically, or you may print and scan.

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* 13. Please upload a copy of your Code of Conduct form. The form can be filled out and signed electronically, or you may print and scan.

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* 14. Have you volunteered with the Academy before?

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* 15. Tell us a little bit about yourself, why you choose to volunteer, why this committee interests you, or anything else you think will strengthen your application.

* 1. Please provide the information we can use to contact you.
Note: Please choose an e-mail you check regularly.

* 2. What is your Academy (Member) ID number?
Volunteers must be current Academy members at the time of application and for the entirety of volunteer term, if appointed. Don't know your member ID? Email membership@audiology.org.