OHA EMS & Trauma Systems Committee Application

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* 1. Contact Information

Name *

Prefered Name (Ex. Thomas -> Tom)

Address *

Suite

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number

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* 2. What is the best email to use to send important documents?

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* 3. What is the best phone number to contact you in case of an emergency?

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* 4. Please check the box for your status of board/committee

New Appointment for board/committee

Reappointment for board/committee

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* 5. Which board/committee are you interested in serving on? (Check all that apply)

Stroke Care Committee

State EMS Committee

State Trauma Advisory Board

Area Trauma Advisory Board (ATAB)

EMS for Children

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* 6. What board/committee seat will you represent?

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* 7. The ATAB I represent is...

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* 8. Letter of Interest:
Please submit an explanation of your interest and relevant experience to support serving on an OHA EMS and Trauma Systems Program board/committee. Use the comment box below or put N/A if you choose to upload a Letter of Interest document.
* A Letter of Interest is required to be considered for appointment to a board/committee.

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* 9. Letter of Interest

Upload PDF, DOC or DOCX Letter of Interest file.

PDF, DOC, DOCX file types only.

Choose File

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* 10. Upload a resume or CV that includes experience and expertise to support your role on the board/committee. PDF, DOC or DOCX file types accepted.
*A resume or CV is required to be considered for appointment to a board/committee. If you are unable to upload, submit file to EMS.TRAUMA@dhsoha.state.or.us

Upload CV/Resume

PDF, DOC, DOCX file types only.

Choose File

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* 11. Which of the following describes your racial or ethnic identity?
*To better assist us in meetings our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against you.

White

Black and African American

Hispanic and Latino/a/x

Asian

American Indian and Alaska Native

Native Hawaiian and Pacific Islander

Middle Eastern/North African

Other (please specify)

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* 12. What is your gender identity?
*To better assist us in meetings our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against you.

Woman

Man

Non-binary

Transgender man

Transgender woman

Two-Spirit

Genderqueer

Other (please specify)