CALL FOR BRAIN INJURY ADVISORY COMMITTEE MEMBERS

Question Title

* 1. Please provide your contact information:

Name *

City/Town *

State/Province *

Email Address *

Phone Number

Question Title

* 2. Are you nominating yourself or someone else?

Myself

Someone Else

Question Title

* 3. If your submission is not for yourself, have you notified the nominee about this nomination?

Yes

N/A

Question Title

* 4. Please provide contact information for your nominee (if different from your contact information):

Name

City/Town

State/Province

Email Address

Phone Number

Question Title

* 5. What position(s) are you nominating for?
Select as many as apply.

Chair-Elect

Survivor of Brain Injury

Relative of a Survivor of Brain Injury

Rehabilitation Professional

Individual who Represents the Brain Injury Association of Ohio

Health Care Professional

Individual who Represents the Public

Question Title

* 6. Please provide a statement (no more than 500 words) that communicates:
-The nominee's commitment to be an active and engaged member of the Brain Injury Advisory Committee
-Why you believe the nominee should be selected to be part of the Committee

The Committee is accepting nominations through 5pm, Friday, April 26, 2019. Questions? Please contact Monica Lichi.

CALL FOR BRAIN INJURY ADVISORY COMMITTEE MEMBERS

Question Title

* 1. Please provide your contact information:

Question Title

* 2. Are you nominating yourself or someone else?

Question Title

* 3. If your submission is not for yourself, have you notified the nominee about this nomination?

Question Title

* 4. Please provide contact information for your nominee (if different from your contact information):

Question Title

* 5. What position(s) are you nominating for? Select as many as apply.

Question Title

* 6. Please provide a statement (no more than 500 words) that communicates:-The nominee's commitment to be an active and engaged member of the Brain Injury Advisory Committee-Why you believe the nominee should be selected to be part of the Committee

* 5. What position(s) are you nominating for?
Select as many as apply.

* 6. Please provide a statement (no more than 500 words) that communicates:
-The nominee's commitment to be an active and engaged member of the Brain Injury Advisory Committee
-Why you believe the nominee should be selected to be part of the Committee