Application Item Writers Panel

Committed to Excellence; Passionate about Care

Recertification Audit and GI Specific Audit Committee Application

The American Board of Certification for Gastroenterology Nurses is seeking volunteers to serve on ABCGN Committees. Qualified, highly motivated and professionally committed nurses are needed to assist in Recertification packet review and GI specific reviews. Contact hours will be awarded to committee members under Category 11. Please review the following qualifications for committee members prior to submitting your applications

REQUIREMENTS

1. Maintain GI certification 2. Have gone through at least one recertification process (not by testing) 3. Currently employed in gastroenterology nursing 4. SGNA membership preferred 5. Be willing to serve a two-year commitment 6. Attend a committee meeting held during the SGNA Annual Course and/or orientation session 7. Access to computer

APPLICATION

Directions: Please type or print all the requested information. Return the form with your personal narrative to: [email protected] or ABCGN Headquarters 330 North Wabash, Suite 2000, Chicago, IL 60611. Please indicate which committee you are interested in.

NAME:______

COMMITTEE PREFERENCE: Recertification GI Audit No preference

1. Have you attended an Item Writers Workshop? Yes No (if yes, how many times?) ______

2. When did you last recertify? ______

3. Credentials______

4. Preferred Fax: ______Preferred e-mail______

5. Present Title:______

6. Present Employer: ______7. Setting for practice: (Select One) Hospital Ambulatory Care Center Free Standing Endoscopy Center Office Surgery Other (specify) ______

8. Past regional and/or national involvement ______

9. Areas of expertise and interest______

10. Please tell us why you feel you are qualified to be on this committee in 100 words or less. ______

Please submit additional pages if needed.

By submitting this form, I attest to the accuracy of the information provided. I understand that my committee assignment will be for a period of two years, and if selected, I will have to sign a confidentiality agreement.

Signature: ______

Date: ______