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Academy of Certified Brain Injury Specialists (ACBIS) Volunteer Application
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1.
Please indicate your preferred salutation.
(Required.)
Mr.
Mrs.
Ms.
Mx.
Dr.
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2.
Please enter your contact information.
(Required.)
Name
Organization
Address
Address 2
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Country
Email Address
Phone Number
3.
BIAA and ACBIS Organizational Involvement in the past 10 years
Organization Name, Board/Committee/Workgroup Name and Dates of Service
Organization Name, Board/Committee/Workgroup Name and Dates of Service
Organization Name, Board/Committee/Workgroup Name and Dates of Service
Organization Name, Board/Committee/Workgroup Name and Dates of Service
4.
Other Organizational Involvement in the past 10 years
Organization Name, Board/Committee/Workgroup Name and Dates of Service
Organization Name, Board/Committee/Workgroup Name and Dates of Service
Organization Name, Board/Committee/Workgroup Name and Dates of Service
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)
(Required.)
Academy
Advanced Practice
CBIS/CBIST
Concussion
Brain Injury Fundamentals
Governance
Other (please specify)
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6.
Highest education level (please choose one).
(Required.)
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).
(Required.)
Current Role
Past Experience
Administration
Current Role
Past Experience
Case management
Current Role
Past Experience
Counselor
Current Role
Past Experience
Family or individual counseling
Current Role
Past Experience
Law
Current Role
Past Experience
Marketing
Current Role
Past Experience
Music therapy
Current Role
Past Experience
Neurology
Current Role
Past Experience
Neuropsychology or psychology
Current Role
Past Experience
Nursing
Current Role
Past Experience
Occupational therapy
Current Role
Past Experience
Philanthropy/fundraising
Current Role
Past Experience
Physiatry
Current Role
Past Experience
Physical therapy
Current Role
Past Experience
Recreation therapy
Current Role
Past Experience
Research
Current Role
Past Experience
Social work
Current Role
Past Experience
Speech & language pathology
Current Role
Past Experience
Teacher/educator
Current Role
Past Experience
Vocational counseling
Current Role
Past Experience
Other (specify)
Current Role
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%.
(Required.)
Administration
Direct Hands-On Care
Education/Teaching
Research
Staff Supervision
Other (specify)
Other (specify)
9.
List all current Board Specialty Certifications you maintain.
Organization / Certification Type
Organization / Certification Type
Organization / Certification Type
Organization / Certification Type
10.
List professional honors and awards you have received.
Organization/Honor type or Award name/Year(s) received
Organization/Honor type or Award name/Year(s) received
Organization/Honor type or Award name/Year(s) received
Organization/Honor type or Award name/Year(s) received
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.
(Required.)
Current Role
Past Experience
Acute medical care (e.g. ICU, trauma, inpatient medical)
Current Role
Past Experience
Community re-entry
Current Role
Past Experience
Extended care (e.g. skilled nursing facility)
Current Role
Past Experience
Home/community
Current Role
Past Experience
Military or veterans hospital/rehabilitation
Current Role
Past Experience
Outpatient
Current Role
Past Experience
Post-acute rehabilitation
Current Role
Past Experience
Research
Current Role
Past Experience
School/education (specify type)
Current Role
Past Experience
Specialized acute inpatient rehabilitation
Current Role
Past Experience
Sub-acute rehabilitation
Current Role
Past Experience
Other (specify)
Current Role
Past Experience
Other (please specify)
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13.
Organization characteristics (please respond in accordance with your organization).
(Required.)
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
(Required.)
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
(Required.)
Female
Male
Transgender
Prefer Not to Say
Other (please specify)
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16.
Ethnic Representation. Source: census.gov
(Required.)
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
(Required.)
Under 30
30-39
40-49
50-59
60-69
70+
Prefer Not to Say
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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?
(Required.)
I am interested in being an ACBIS volunteer only (serving on ACBIS subcommittees, workgroups, etc.).
I am interested in serving on the ACBIS Board of Governors (as a board member, participation and time commitment is required).
I am interested in serving in either capacity.
19.
How did you hear about this opportunity?
Current Progress,
0 of 19 answered
