Vascular Access Certification Corporation Board of Directors Application

Position Desired: Please indicate the position desired by numbering your order of preference (1 = most desired, 4 = least desired, 0 = not desired)

	Preference
President Elect
Treasurer Elect
Director
Public Member

Position you are applying for (check all that apply)*

DirectorTreasurer-Elect

Name*

First NameLast Name

Credentials:*

Title:*

Name of Facility/Institution*

Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone:*

Area CodePhone Number

Work Fax :

Area CodePhone Number

E-mail:*

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone:

Area CodePhone Number

Home Fax:

Area CodePhone Number

Home E-mail:

example@example.com

Indicate highest degree held*

Certificate course description if applicable

Number of years in vascular access*

Certification in vascular access

yesno

Year of initial certification

Year(s) of recertification

Which vascular access organizations are you a member of and for how long?:*

Do you hold a certification in another healthcare related professional area?*

yesno

If "yes" please list

Indicate areas of prior or current vascular access experience. Then, for each discipline/program area, indicate whether you had oversight responsibility or participation. Please choose one box for each discipline/program area as applicable. *

	Oversight Responsibility	Participation
Acute Care
Behavioral Health
Child Care
Community Health/Public Health
Correctional Health
Home Health
Long-term Care
Ambulatory Care (office,clinic,surgery, etc)
Rehabilitation
Occupational Health/Environmental Safety
Performance Improvement
Risk Management
Patient Safety
Infection Control
Other

Management Experience (check all that apply): *

Department Management with budget responsibilitiesDirect Supervision of 1-4 StaffDirect Supervision of 5 or greater staffManagement/Supervisory Responsibilities for greater than 3 yearsN/A

Please mark in the box for each leadership positions held in an organization(s). If you held the same position for more than one year, you must list each year under the year(s) served.*

	Year(s) Served	Local	State	Regional	National	International	Other Healthcare Related	Other (non-healthcare related)
President
President-Elect/
Vice-President
Treasurer
Secretary
Board Member
Nominating Comm.
Comm./Council/ Program Chair or Co-Chair
Committee/Council Member
Task Force Chair
Task Force Member
Section Chair
Focus Group Leader
Special Projects
N/A

Describe how your leadership experience would be an asset to the VACC board. Include a philosophy statement clearly describing your philosophy on certification and specific strategies and goals to help VACC achieve its vision and mission (250 words max)*

LEADERSHIP CHARACTERISTICS

VACC Board of Directors and Nominating Committee have identified various leadership competencies individual board members must possess in order for the certification corporation to achieve its mission and vision. Leadership competencies are collections of skills and knowledge individuals must demonstrate to effectively perform their jobs. Skills are an individual’s personal capability to do something, such as think strategically or communicate effectively. Knowledge is the information and understanding an individual must have in order to be effective, such as principles of accounting.

For each leadership competency listed, please provide a brief description (narrative or bullets) of how your previous/current experience has helped you achieve this competency. Your examples should highlight your previous organizational experiences, outcomes, and lessons learned in the organizations listed in section IV.

A. Developing self and others—the ability to continuously learn and grow, and promote the development of others (no more than 150 words) Example: Served as a mentor for peers or someone new to the field of vascular access*

B. Collaboration—the ability to manage relationships, build consensus and promote strong teamwork and garner commitment and participation of others to achieve and effect positive change (no more than 150 words) Example: Served as a leader for a multi-disciplinary performance improvement team that focused on reducing bloodstream infections. The team efforts resulted in a 30% reduction rate.*

C. Representing and advancing the profession—the ability to professionally and positively represent, advocate for and advance the vascular access profession (no more than 150 words) Example: Testifying before a governmental agency on an vascular access issue.*

D. Performance Improvement — the ability to inspire confidence and action to lead and implement change (no more than 150 words) Example: Championed a culture change for patient safety to reduce readmissions; Served as a leader for a performance improvement team that focused on reducing CLABSI and improve vessel preservation. The team efforts resulted in a 30% reduction rate.*

E. Critical Thinking Skills —the ability to make astute decisions and communicate sound, fact-based and timely choices and decisions that reflect the long and short-term interests of the profession (no more than 150 words) Example: Proposed plan for CLABSI surveillance in the organization despite administrative resistance due to cost*

F. Leveraging technology—the ability to embrace and leverage technology to enable analysis and decision making related to vascular access (no more than 150 words) Example: Collaborated with IT to develop an alert system to identify high risk vascular access patients *

G. Financial management—the ability to interpret and appropriately use data within financial statements to promote the financial position of the vascular access care (no more than 150 words) Example: Presented a business case to administration and obtained additional resources for the vascular access team*

H. Communicating for results—the ability to openly, efficiently and compellingly express ideas as a representative of the organization (no more than 150 words) Example: Submitted editorial on zero-tolerance of CLABSI to the media*

Please submit three (3) references

1. Facility/Institution/Agency:*

Title or professional relationship:*

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState/Province

Postal/Zip CodeCountry

Phone Number*

Area CodePhone Number

Email*

example@example.com

2. Facility/Institution/Agency:*

Title or professional relationship:*

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal/ Zip CodeCountry

Phone Number*

Area CodePhone Number

Email*

example@example.com

3. Facility/Institution/Agency:*

Title or professional relationship:*

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Email*

example@example.com

Biographical Profile: This should be written in the third person and worded EXACTLY as you wish it to appear on the ballot. Indicate achievements and accomplishments in vascular access. (no more than 250 words)

Photograph: Please submit a recent color photo with your application in .jpg file format with a minimum 300 dpi.

Browse Files

Attach a current curriculum vitae or resume*

Upload a File

I AFFIRM THE INFORMATION INCLUDED IN THIS APPLICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.*

yes

Signature*

Date Time*