1.Personal Information

Name

Credentials

Place of Employment

Which Nursing Organizations are you currently a member of?

Board(s) currently serving on

2.Tell us how your input on the board creates new perspectives for thinking about board activities or priorities.

3.Describe an example of how your input resulted in an 'A-Ha!' moment for the board members.

4.How is the impact of your board service unique from the impact of other board members?

5.Please provide an example of how your nursing experience influenced change in board discussions or decisions.

6.What advice do you have for nurses seeking their first board role?

7.Any additional comments you wish to share:

8.Consent to be interviewed – Nurses on Boards Coalition

I hereby consent to being photographed, interviewed, videotaped/filmed and give permission for the above materials to be used in marketing materials for the Nurses on Boards Coalition.

I agree that the Nurses on Boards Coalition may use the negatives, prints or video prepared from my photographs, words or written materials reflecting my interview for any purposes and in such manner as they may choose, including but not limited to use in informational or promotional materials about the Nurses on Boards Coalition, including: News coverage by television, newspaper, radio, internet or other media, video news releases, advertisements/marketing materials, internal and external video productions.