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SANDRA BOBBITT CONTINUING EDUCATION SCHOLARSHIP

APPLICATION

AOHP recognizes the value and need for members to continually update their knowledge and skills in the field of occupational health and also is aware of the financial burden that may result. To support these educational endeavors, the Association offers limited funds on an annual basis for active members in good standing. Awards shall be a maximum of $600 per member per year. Four scholarships will be awarded annually to members applying for assistance to attend the Association’s annual conference. Recipients will receive 1 main conference registration and 1 night lodging at the conference hotel. To qualify, applicants for the Sandra Bobbitt continuing education scholarship must have completed at least one full year as an active AOHP member. Please submit the following information to AOHP Headquarters via email. Headquarters will forward all applications to the executive vice president

NOTE: The deadline for scholarship applications for the AOHP annual conference is July 1 st of the conference year. Refer to the Continuing Education Scholarship Guidelines for important information when you apply for a scholarship. These guidelines may be obtained from your chapter president or on-line at www.aohp.org.

Please print or type all information Member Name and Credentials: Address: Email: Work Phone: Home Phone: Chapter: Years of AOHP Membership: Employer: Position/Title: Course Title for which the application is made: Location: Sponsoring Organization if not AOHP Conference Description: (attach conference brochure copy; N/A for AOHP conference)

CRITERIA 1. Activity within AOHP: List offices held (national, regional, chapter), committee/task force chair or participation, presentations, and other contributions within the last two years:

Year Activity 2. Personal or Professional Achievements:

3. Current Certification(s);

Type Year(s)

4. Course work (beyond basic nursing degree) toward baccalaureate or advanced degree;

5. Occupational health CEU courses attended (workshops, seminars within the past two years)

6. Community service: list any activities in which you have participated within the last two years, in the community, as a representative of the nursing or allied health profession (include political activity):

7. Publications: list published articles in the occupational health field which you have written within the past five years. Provide publication title, article title, and date (do not send copies).

8. How would this course benefit the member and/or Association?

9. Are there any extenuating circumstances (needs, hardship, etc.)? Describe specifics.

Estimate of Total Expenses: Cost of Tuition: Travel: Lodging: Food: Misc: Total:

Are you receiving any assistance from other sources? Yes No

If yes, indicate amount of assistance.

Scholarship amount requested: (AOHP Conference awardees receive one main conference registration plus one hotel night.)

If selected for this award, I do do not wish the Association to forward a copy of my letter of scholarship acceptance to my supervisor/manager.

If you wish a letter sent, provide the name, title, and address of direct report. Awardee Direct Report Name/Title: Complete address:

Applicant’s Signature Date

Email completed application to: [email protected]

Attention: Sandra Bobbitt Application

NOTE: If any part of the application is missing, your application will be returned to you as incomplete.

Review Date: 08/04, 08/07, 08/13 Revision Date: 10/04, 08/05, 08/09, 06/11, 12/13 Supersedes Policy Dated: 10/95, 08/00 Effective Policy Date: 03/92 COMPLETED BY AOHP EVALUATORS ONLY ************************************************************************************** Evaluation Instrument

Instructions to evaluators Please evaluate this scholarship application based on the criteria listed below, assigning a numerical value to each criterion. The total score of the numerical ratings is used as an indicator in the scholarship selection process.

Note: The executive vice president has verified that the attached application meets all eligibility requirements. This applicant is eligible to receive a total of $ if this scholarship is granted.

Signature of Executive Vice President Date

Name of applicant:

Scholarship requested for:

For Section 1: 2 = present/meets; 1 = absent/does not meet

For Section 2: Rating Scale AND the degree to which the criterion is met is:

2 Exceeds all requirements 1 Minimum requirements met 0 Minimum requirements not met

# CRITERIA SCORE Section 1: Application and course material (non-AOHP conference only) 1 Course material is relevant to the practice of occupational health in healthcare 2 Course provides CEUs 3 Application submitted by deadline (30 days prior to course) 4 Application is complete:(a) application form, (b) conference brochure

Section 2: AOHP Participation, Personal and Professional Achievements 1 Participation/involvement with AOHP activities (within the past 2 years) 2 Personal or professional achievements 3 Current certifications 4 Course work toward a degree 5 Occupational health CEU courses attended (within the past 2 years) 6 Community service (within the past 2 years) 7 Publications (within the past 5 years) 8 Course benefit to the member and/or Association 9 Extenuating circumstances, need, hardship?

TOTAL SCORE (minimum score of 8 will be considered) Comments:

Financial Need (to be considered in event of tie, multiple applicants.):

Signature of reviewer Date

PLEASE RETURN THIS FORM TO THE EVP WITHIN ONE WEEK OF RECEIPT.

Review Date: 06/02, 08/04, 08/07, 08/09, 08/13 Revision Date: 10/04, 08/05, 06/11, 12/13 Supersedes Policy Dated: 10/95, 12/96 Effective Policy Date: 03/94