Application - Health Policy Health Policy Committee Application Question Title * 1. Your Contact Information: Your Name List Credentials Address City/State/Zip Email Preferred Phone Question Title * 2. How long have you been a member of ANNA? Question Title * 3. What is the expiration date of your ANNA membership? Question Title * 4. What is your current professional role? Question Title * 5. Have you ever served in another national role, committee or SPN role with ANNA? If yes, please list them here: Question Title * 6. Please rate your skill level in these areas: Excellent Very good Adequate Needs work General computer skills General computer skills Excellent General computer skills Very good General computer skills Adequate General computer skills Needs work Email communication Email communication Excellent Email communication Very good Email communication Adequate Email communication Needs work Saving/attaching files Saving/attaching files Excellent Saving/attaching files Very good Saving/attaching files Adequate Saving/attaching files Needs work Organization skills Organization skills Excellent Organization skills Very good Organization skills Adequate Organization skills Needs work Meeting deadlines Meeting deadlines Excellent Meeting deadlines Very good Meeting deadlines Adequate Meeting deadlines Needs work Word Word Excellent Word Very good Word Adequate Word Needs work Excel Excel Excellent Excel Very good Excel Adequate Excel Needs work PowerPoint PowerPoint Excellent PowerPoint Very good PowerPoint Adequate PowerPoint Needs work Question Title * 7. Please indicate your answer below: Yes No Needs work Do you generally have daily access to email? Do you generally have daily access to email? Yes Do you generally have daily access to email? No Do you generally have daily access to email? Needs work Do you have daily access to the internet? Do you have daily access to the internet? Yes Do you have daily access to the internet? No Do you have daily access to the internet? Needs work Can you download a file? Can you download a file? Yes Can you download a file? No Can you download a file? Needs work Please indicate any challenges you have with communicating via email: Question Title * 8. According to the Role Description, are you qualified for this role? Yes No Other (please specify) Question Title * 9. Can you participate in monthly conference calls on a weekday or evening? Yes No Comments Question Title * 10. Which of these meetings have you attended? ANNA National Symposium ANNA Fall Meeting ANNA Health Policy Workshop NIWI Other Health Policy Workshop (describe below) Other: Question Title * 11. Why are you interested in serving on the Committee? Question Title * 12. What is the greatest strength you would bring to the Committee? Question Title * 13. What experiences would you like to share in regards to previous health policy activities? Question Title * 14. Is there anything else you would like to share with the Committee? Next
