2023/2024 EH Leadership Academy Application Question Title * 1. Your information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. Employment Information Employer Name (full name, no abbreviation) Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 3. Agency type State Tribal Local Territorial Other (please specify) Question Title * 4. Do you work full time for this agency? Yes No Other (please specify) Question Title * 5. Supervisor's name Question Title * 6. Supervisor's email Question Title * 7. Do you currently hold a Registered Sanitarian/Registered Environmental Health Specialist credential? Yes No Question Title * 8. What agency issues your RS/REHS credential? Question Title * 9. Are you a current member of NEHA? Yes No Question Title * 10. Please indicate if you are a member of a NEHA affiliate. Alabama Environmental Health Association Alaska Environmental Health Association Arizona Environmental Health Association Arkansas Society of Professional Sanitarians Business and Industry Affiliate California Environmental Health Association Colorado Environmental Health Association Connecticut Environmental Health Association Florida Environmental Health Association Georgia Environmental Health Association Idaho Environmental Health Association Illinois Environmental Health Association Indiana Environmental Health Association Iowa Environmental Health Association Jamaica (IPO) Kansas Environmental Health Association Kentucky Environmental Health Association Louisiana Environmental Health Association Massachusetts Environmental Health Association Michigan Environmental Health Association Minnesota Environmental Health Association Missouri Environmental Health Association Montana Environmental Health Association National Capital Area Environmental Health Association Nebraska Environmental Health Association Nevada Environmental Health Association New Jersey Environmental Health Association New Mexico Environmental Health Association New York State Conference of EH Directors North Carolina Public Health Association- EH Section North Dakota Environmental Health Association Northern New England Environmental Health Association Ohio Environmental Health Association Oklahoma Society of Environmental Health Professionals Oregon Environmental Health Association Past Presidents Rhode Island Environmental Health Association EH section of South Carolina Public Health Association Tennessee Environmental Health Association Texas Environmental Health Association Uniformed Services Environmental Health Association Utah Environmental Health Association Virginia Environmental Health Association Washington State Environmental Health Association West Virginia Association of Sanitarians Wisconsin Environmental Health Association Wyoming Environmental Health Association I am not a member of a NEHA affiliate. Question Title * 11. Staff size of workforce 1-10 11-25 26-50 51+ Question Title * 12. Job title Question Title * 13. Job responsibilities Question Title * 14. Years of environmental health experience Question Title * 15. Attendance at the NEHA's 2024 Annual Educational Conference (AEC) is mandatory. The 2024 AEC location will be Pittsburgh, PA. Can you commit to attending? Yes No Maybe Question Title * 16. Please list any other leadership training programs you have attended. Question Title * 17. What areas of environmental health have you worked in? (Check all that apply) Aquatic Health / Recreational Waters Climate & Health Data and Informatics Emergency Preparedness & Response Food Safety Healthy Homes & Communities Indoor Air Quality Infectious & Vector-borne Diseases On-site Wastewater Outdoor Air Quality Solid and Hazardous Waste Water Quality (Drinking water, Stormwater, etc.) Other (please specify) Question Title * 18. Please list all credentials, certifications, and/or degrees Question Title * 19. A one-page letter of support to participate in this program from your department head or immediate supervisor is required. Either upload a copy here or email a PDF copy to ehlaprogram@neha.org. PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File A one-page letter of support to participate in this program from your department head or immediate supervisor is required. Either upload a copy here or email a PDF copy to ehlaprogram@neha.org. Question Title * 20. Please provide a personal statement, so we can learn more about you. Your statement should be no more than 500 words and include what you desire, what you expect to gain, and what it means personally to participate in NEHA’s Leadership Academy. Also, include your leadership skills, career aspirations, and any other information you believe would make you a good candidate. Question Title * 21. The tuition for this program is $2,000. Will your employer be able to provide financial assistance for you to attend program? Yes No Unsure Question Title * 22. If you would like to be considered for a need-based scholarship, please describe why support is needed. Question Title * 23. By typing your full name below, I hereby certify that the above information is complete and accurate. I also fully understand and agree to the following:• Attend all online training modules of NEHA’s leadership program, which requires a commitment of one year. The modules will be once a month and last 4 hours.• Attend all modules associated with the leadership academy at NEHA’s 2024 Annual Educational Conference. Please be aware that the cost of AEC registration and any travel or lodging are not included in the program fee.• Complete all required readings before the monthly modules and/or submit course assignments on time.• Show up on time to all online and in-person program modules, ready to learn.• Receive a written letter of support from my department head to be a part of this leadership academy. Written letter of support must be submitted with the application.• Participate in group settings when the program assignment demands such.• Engage in dialogue with fellow program participants and instructor to enrich the program.• Provide feedback on program content and material to the leadership program’s administrative team to help improve the program.• Agree to participate in either one-on-one or group sessions with a mentor for a set amount of time, once a month.• Work on a year-end project which must benefit either your organization, community served, or the EH workforce. • Complete all post module and program evaluations. Done