National Asthma Educator Certification Board

Board of Directors Nomination Application

Name:

Preferred mailing address:

City: State: Zip+4:

Home #: Business #: Mobile #: Fax#:

E-mail:

Optional

In our efforts to continue to reach our goal of developing a culturally diverse Board of Directors reflecting a distribution of diverse age, gender, ethnicity, and professional discipline please complete the following:

DOB: Sex: Ethnic Group:

Business/Profession:

Current Title: Credentials:

Skills of Interest to NAECB:

Currently AE-C: YES NO If yes, certificate number and date of expiration:

Area(s) of Expertise:

Please answer the following questions.

Why are you interested in serving on the Board of Directors?

Which other national boards or committees have you chaired or served on?

What contributions have you made to these boards in terms of offices held, committee chairmanships, community outreach, or other participation?

The Board of Directors is a group of members empowered to act for the organization as a whole. How do you see yourself fitting into this role?

How will your life, professional, and/or social experiences help you contribute to the work of the Board?

What specific qualifications do you have that meet the requirements for membership on the Board?

How will you contribute to the goal of Board Diversity?

The Board of Directors has at minimum four board meetings per year. Two are in-person and two are by conference call.

The in-person meetings last between 1-3 days and the conference calls are usually 2-3 hours. Are you willing to commit to participating in all four meetings? Yes No

Have you ever taught in a review for the NAECB – A-EC examination that has be recorded, or authored a review program for the AE-C examination that has been distributed (video/DVD, print, etc.)?

Yes No If yes, for whom and when?

Please check one: Self-nomination I was recommended for nomination to the National Board by:

Name Title:

Association/OrganizationPhone #:

I agree to accept nomination to the Board if selected by the Nominating Committee. I have read the Board Member job description and am confident I will be able to fulfill all requirements if elected to serve on the Board of Directors.


Signature: Date:

DEADLINE: August 10, 2015

PLEASE FAX SIGNEDAPPLICATIONS TO FAX NUMBER BELOW

Mail application to:

NAECB,Inc.

4001 E. Baseline Road, Suite 206

Gilbert, AZ 85234

Phone: 877 408-0072 Fax: 480 398-4081

National Asthma Educator Certification Board of Directors Application

Skills Evaluation Form

Represented area – Please mark your primary position.

Behavioral scientist

Certified Health Educator (CHES)

Nursing

Pharmacist

Physician

Physician Assistant

Respiratory Therapy, Pulmonary Function Technologist

Other, Please specify: ______

Areas of Practice (allergy, pulmonary, primary care, etc.)

List your professional affiliations:

Please rank your top three skills from the following list:

Administrative Experience in Healthcare

Oral and Written Communication Skills

Strategic Planning Experience

Public Relations/ Marketing Expertise

Organizational Infrastructure Development

Exam Development Skill

Experience in Research and Outcomes Assessment

Fund Raising Expertise

Legal Experience

Reimbursement and Coding Expertise

Business Development Expertise

Accreditation Experience

Advocacy Expertise

Provide a self-evaluation of Initiative and Energy and give an example (1 low - 5 high)

Job Description for NAECB Board Member

General Expectations

  1. Know the NAECB’s mission, purpose, goals, policies, programs, services, strengths and needs.
  2. Suggest nominees for the Board.
  3. Serve in leadership positions or undertake special assignments willingly when asked.
  4. Avoid prejudiced judgments on the basis of information received from individuals and urge those with grievances to follow established policies and procedures.
  5. Follow trends in NAECB’s field of interest.
  6. Bring a sense of humor to board work.
  7. Responsible for our product – the NAECB examination and certification process (AE-C).

Meetings

  1. Prepare for and participate in ALL Board and committee meetings, and other organizational activities.
  2. Ask timely and substantive questions while supporting the majority decision.
  3. Maintain confidentiality of the Board’s executive sessions.
  4. Speak on behalf of the Board when asked to do so by authorized persons.
  5. Suggest agenda items periodically for Board and committee meetings to ensure that significant policy-related matters are addressed.
  6. Board members are expected to attend all face-to-face and telephonic meetings.

Relationship with Staff

  1. Counsel the Administrative Director as appropriate and offer support.
  2. Avoid asking for special favors of the staff without prior consultation with the Administrative Director, Board Chair, or Committee Chairs.

Avoid Conflict

  1. Serve the NAECB as a whole rather than special interest groups.
  2. Avoid even the appearance of a conflict of interest, and disclose any possible conflicts to the Board.
  3. Maintain independence and objectivity and do what a sense of fairness, ethics and personal integrity dictate.
  4. Never accept or offer favors or gifts from or to anyone who does business with the NAECB.
  5. In order to avoid any perception of conflict of interest, Board of Director members may not host, develop, create, teach, or participate in any way in NAECB Examination review or preparatory courses, whether the courses are face-to-face, online, via webinar, print, DVD or any other electronic forms.

Fiduciary Responsibilities

  1. Exercise prudence with the Board in the control and transfer of funds.
  2. Faithfully read and understand the NAECB’s financial statements and otherwise help the Board fulfill its fiduciary responsibility.

Fund Raising

  1. Give an annual gift according to personal means.
  2. Assist in development by implementing fundraising strategies through personal influence with others: corporations, foundations, individuals.
  3. Advocate NAECB’s mission in your organization and professional societies.

I am willing and able to perform these responsibilities in accordance with my position as a NAECB Board member, if elected.

______

Signature Date

National Asthma Educator Certification Board of Directors Application

Biosketch

350 word limit describing your background, expertise in asthma education

and your potential contributions to the board!

If you are selected to be on the ballet, this will be included to help certificants in the vote selection.

7/2014