oena delegate form

Name

First Name Last Name
Completed applications must be recieved by JUNE 15th at 1700. Those recieved late may not be considered for General Assembly 2022
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Chapter

Akron Eastern Central Ohio, Columbus Greater Cleveland Greater Cincinati Toledo Seagate
What is your current role/title
Have you previously attended General Assembly as an Ohio ENA delegate?

Yes No

Please select and enter points from all applicable categories that apply from January 1, 2021 to December 31, 2021.

At the end of the form total your points, and provide any supporting data, certificates or documentation to support selected criteria
Served as an OHIO ENA (OENA) delegate at 2021 General Assembly (10 Points)
Attended as a chapter delegate to at least 50% of OENA meetings (10 points)
Served as an OENA officer (15 points)
Served as an ENA chapter officer (10 points)
Membership on an ENA taskforce or liaison workgroup National level (15 points), OENA or chapter level (10 points). Please list out the committees with claimed points
Attended Local chapter meeting(s) 1 point per meeting
Attended OENA meeting: NOT as a chapter delegate (5 points)
Attended OENA awards banquet (NA for 2021)
Attended National ENA State & Chapter Leadership Meeting, SCLO/LO (15 points)
Attended ENA National Annual conference (15 points)
Attended ENA Day on the Hill DOTH (10 points)
Attended chapter educational symposiums or offerings (5 points)
Received any awards or recognition for contributions to Emergency Nursing, such as but no limited to FAEN designation, state award, chapter award, daisy nomintation/award, or hospital award (10 points-- list the award)
Achieved or maintains BCEN certifications CEN, CPEN, TCNR, CTRN, CFRN (claim 10 points per certification & list each certification )
Achieved or maintains additional healthcare related specialty certifications as recognized by AACN such as CCRN (10 points per certification & list each certification)
Achieved or maintains additional healthcare related licensure such as National Registry or state EMS cards (10 points per certification & list each certification)
TNCC course Director/Instructor (10 points); TNCC current provider card (5 points)
ENPC course Director/Instructor (10 points); ENPC current provider card (5 points)
Participated in a virtual CATN or ATCN course (5 points)
Obtained and maintains GENE programming (5 points)
Served as a SANE (5 points)

Lectured in Emergency Nursing: list the topic, date, location/host of lecture (5 points)
Conducted emergency nursing research, quality improvement, or evidence-based practice initiatives: list the name of the project (5 points)
Published in a peer-reviewed article in JEN or other healthcare journals. List the article citation with the doi (5 points per article)
Volunteer activity within Healthcare such as wellness activities, health fairs for the general public, schools, etc. List the date time and activity completed (5 points)
Recruited new members to ENA. List each member recruited. (1 point per member)
POINT TOTAL:
Please add any supporting information or notes you feel would assist the OENA Membership Liaison with the review of your application:
Please add any supporting documents you feel would assist the OENA Membership Liaison with the review of your application.

Cancel of
All communication from OENA regrding this application will occur via email. If you have any questions please enter them here. Announcement of the slate of delegates will occur at the JUNE 24th OENA meeting. Attendance is recommended
Signature: My signature verifies that I am interested in serving as a 2022 OENA delegate at General Assembly. Addition prep-work, attendance at OENA August 26th meeting; and completion of ENA delegate on-line training to prepare for GA is encouraged.

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Please select and enter points from all applicable categories that apply from January 1, 2021 to December 31, 2021.