Academy of Certified Brain Injury Specialists (ACBIS) Volunteer Application Survey

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* 2. Please enter your contact information.

Name

Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. BIAA and ACBIS Organizational Involvement in the past 10 years

Organization Name, Board/Committee/Workgroup Name and Dates of Service

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* 4. Other Organizational Involvement in the past 10 years

Organization Name, Board/Committee/Workgroup Name and Dates of Service

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* 5. Areas of ACBIS Program Interest (please select all that apply)

Academy

Advanced Practice

CBIS/CBIST

Concussion

Brain Injury Fundamentals

Governance

Other (please specify)

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* 6. Highest education level (please choose one).

Associate

Bachelors

Masters

Doctorate

None of the above

Please indicate degree type here (e.g. PsyD, EdD, etc.)

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* 7. Discipline (indicate all with which you have experience, past or present).

	Current Role	Past Experience
Administration	Administration Current Role	Administration Past Experience
Case management	Case management Current Role	Case management Past Experience
Counselor	Counselor Current Role	Counselor Past Experience
Family or individual counseling	Family or individual counseling Current Role	Family or individual counseling Past Experience
Law	Law Current Role	Law Past Experience
Marketing	Marketing Current Role	Marketing Past Experience
Music therapy	Music therapy Current Role	Music therapy Past Experience
Neurology	Neurology Current Role	Neurology Past Experience
Neuropsychology or psychology	Neuropsychology or psychology Current Role	Neuropsychology or psychology Past Experience
Nursing	Nursing Current Role	Nursing Past Experience
Occupational therapy	Occupational therapy Current Role	Occupational therapy Past Experience
Philanthropy/fundraising	Philanthropy/fundraising Current Role	Philanthropy/fundraising Past Experience
Physiatry	Physiatry Current Role	Physiatry Past Experience
Physical therapy	Physical therapy Current Role	Physical therapy Past Experience
Recreation therapy	Recreation therapy Current Role	Recreation therapy Past Experience
Research	Research Current Role	Research Past Experience
Social work	Social work Current Role	Social work Past Experience
Speech & language pathology	Speech & language pathology Current Role	Speech & language pathology Past Experience
Teacher/educator	Teacher/educator Current Role	Teacher/educator Past Experience
Vocational counseling	Vocational counseling Current Role	Vocational counseling Past Experience
Other (specify)	Other (specify) Current Role	Other (specify) Past Experience

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* 8. Considering how you use your time in your current role, please estimate the percentage of time you dedicate to each area. Answers should add up to 100%.

Administration

Direct Hands-On Care

Education/Teaching

Research

Staff Supervision

Other (specify)

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* 9. List all current Board Specialty Certifications you maintain.

Organization / Certification Type

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* 10. List professional honors and awards you have received.

Organization/Honor type or Award name/Year(s) received

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* 11. List all current professional memberships you possess.

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* 12. Please indicate your work setting. This is not an exhaustive list; please use the Other field if your work setting is not indicated. Check all that apply.

	Current Role	Past Experience
Acute medical care (e.g. ICU, trauma, inpatient medical)	Acute medical care (e.g. ICU, trauma, inpatient medical) Current Role	Acute medical care (e.g. ICU, trauma, inpatient medical) Past Experience
Community re-entry	Community re-entry Current Role	Community re-entry Past Experience
Extended care (e.g. skilled nursing facility)	Extended care (e.g. skilled nursing facility) Current Role	Extended care (e.g. skilled nursing facility) Past Experience
Home/community	Home/community Current Role	Home/community Past Experience
Military or veterans hospital/rehabilitation	Military or veterans hospital/rehabilitation Current Role	Military or veterans hospital/rehabilitation Past Experience
Outpatient	Outpatient Current Role	Outpatient Past Experience
Post-acute rehabilitation	Post-acute rehabilitation Current Role	Post-acute rehabilitation Past Experience
Research	Research Current Role	Research Past Experience
School/education (specify type)	School/education (specify type) Current Role	School/education (specify type) Past Experience
Specialized acute inpatient rehabilitation	Specialized acute inpatient rehabilitation Current Role	Specialized acute inpatient rehabilitation Past Experience
Sub-acute rehabilitation	Sub-acute rehabilitation Current Role	Sub-acute rehabilitation Past Experience
Other (specify)	Other (specify) Current Role	Other (specify) Past Experience

Other (please specify)

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* 13. Organization characteristics (please respond in accordance with your organization).

Parent Organization (e.g. Brightspring, Sevita, Dept of Veterans Affairs)

Number of persons with brain injury served annually in program/facility in which you work

Number of persons with brain injury served annually by parent organization

Public Non-profit/for-profit - Private non-profit/for-profit

Community Size (urban/suburban/rural)

Estimated number of program/facility CBIS:

Estimated number of program/facility CBIST:

Estimated number of program/facility CBIS-AP:

Estimated number of program/facility Brain Injury Fundamentals Certificants:

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* 14. Geography (please choose your geographic location). Source: hhs.gov

Region 1 - Boston (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont)

Region 2 - New York (New Jersey, New York, Puerto Rico, and the Virgin Islands)

Region 3 - Philadelphia (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia)

Region 4 - Atlanta (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee)

Region 5 - Chicago (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin)

Region 6 - Dallas (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas)

Region 7 - Kansas City (Iowa, Kansas, Missouri, and Nebraska)

Region 8 - Denver (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming)

Region 9 - San Francisco (Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau)

Region 10 - Seattle (Alaska, Idaho, Oregon, and Washington)

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* 15. Gender (as you currently describe yourself). Source: census.gov

Female

Male

Transgender

Prefer Not to Say

Other (please specify)

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* 16. Ethnic Representation. Source: census.gov

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Some Other Race

Prefer Not to Say

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* 17. Age

Under 30

30-39

40-49

50-59

60-69

70+

Prefer Not to Say

Academy of Certified Brain Injury Specialists (ACBIS) Volunteer Application

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* 1. Please indicate your preferred salutation.

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* 2. Please enter your contact information.

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* 3. BIAA and ACBIS Organizational Involvement in the past 10 years

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* 4. Other Organizational Involvement in the past 10 years

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* 5. Areas of ACBIS Program Interest (please select all that apply)

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* 6. Highest education level (please choose one).

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* 7. Discipline (indicate all with which you have experience, past or present).

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* 8. Considering how you use your time in your current role, please estimate the percentage of time you dedicate to each area. Answers should add up to 100%.

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* 9. List all current Board Specialty Certifications you maintain.

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* 10. List professional honors and awards you have received.

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* 11. List all current professional memberships you possess.

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* 12. Please indicate your work setting. This is not an exhaustive list; please use the Other field if your work setting is not indicated. Check all that apply.

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* 13. Organization characteristics (please respond in accordance with your organization).

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* 14. Geography (please choose your geographic location). Source: hhs.gov

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* 15. Gender (as you currently describe yourself). Source: census.gov

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* 16. Ethnic Representation. Source: census.gov

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* 17. Age

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* 18. As the ACBIS Board considers projects and demographics, would you also be interested in serving on the Board of Governors?

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* 19. How did you hear about this opportunity?