MASSACHUSETTS EMERGENCY NURSES ASSOCIATION

2007 GENERAL ASSEMBLY DELEGATE APPLICATION

Name:  ____________________________________________           Credentials:  ____________________________________

Home Address:  ___________________________________________________________________________________________

                             ___________________________________________________________________________________________

Home Phone#:  ____________________________________              E-mail Address:  _______________________________________

SS# (needed for reimbursement):  ______________________________         ENA #:  ___________________________________

Employer:  ______________________________________________________________________________________________

Chapter Affiliation:  _______________________________________________________________________________________

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You may use additional pages as needed for activities.

I.         MISCELLANEOUS    (*meetings attended from June 1, 2006 through June 1, 2007)                                                #of pts

Number of chapter meetings attended (10 pts/meeting*)                                                                                   _____

Number of state council meetings attended (10 pts/meeting *)                                                                        _____

Current PALS and/or ACLS certification (10 pts each)                                                                                          _____

Current TNCC/ENPC certification  (10 pts each)                                                                                                    _____

EN CARE provider  (10 pts)                                                                                                                                         _____

Recruitment  of a new ENA member (5 pts for each new member)                                                                    _____

Author of a national resolution  (50 pts)                                                                                                                               _____

2006 General Assembly delegate (20 pts)                                                                                                              _____

Attended 2007 Leadership Conference  (10 pts)                                                                                                   _____

Attended 2007 New England Regional Symposium (10 pts)                                                                               _____

                                                                                                                        Subtotal part I                                      _____

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II.       ELECTED OR APPOIN TED ENA POSITIONS

(within the past three (3) years – points given for each position held between 2005 and 2007)

Officer    100 pts                          Committee Chair     50 pts                                 Committee member   25 pts

A.         Chapter level:

Position                                                                 Year held                                                                               # of pts

 

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B.       State Council level:

Position                                                                 Year held                                                                               # of pts

 

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C.         National level:   (Elected office or chair of committee, workgroup or task force          100 pts)

                              (Appointed member of committee, workgroup or task force                 50 pts)

Position held                                                        Year held                                                                               # of pts

 

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                                                                                                                                Subtotal for Part II:             ______

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III.     PROJECT/TEACHING PARTICIPATION  (Participation in the following activities between June 1, 2006 through June 1, 2007)

A.        Lecturer (other than ACLS, TNCC, ENPC, PALS or a lecture required in your employed nursing position)

25 pts per lecture

                                Date                                        Topic                                                                                                                      # of pts

                                _________________________________________________________________________________________

                                _________________________________________________________________________________________

                                _________________________________________________________________________________________

B.        Projects (public education, legislative involvement, ENA fund-raising/contributor, non-ENA special committees or task force)                                     Chair  25 pts                                         Involvement    10 pts

 

Date                                        Project                                                                                                                   # of pts

 

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C.          Research in Emergency Nursing (research outside your place of employment     50 pts/project)

 

Date                                        Project                                                                                                                   # of pts

 

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D.        Publication of topics related to Emergency Care (50 pts for each national journal article/book chapter, 10 pts for MENU article)

Date                                        Topic                                                                                                                      # of pts

 

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E.         CEN (or have made commitment to take the exam within the next year     30 pts)

 

CEN date:   __________________________        CEN #:  ____________________                                           ______

 

                                                                                                                Subtotal for Part III:                            ______

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Part I points:                        _______

Part II points:                       _______

Part III points:                      _______

Total points:                         _______

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Applicant signature:  _________________________________________________       Date:  _____________________________

 

 

Executive Committee review date:  _____________________________________

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IMPORTANT REMINDER:  The Massachusetts State Council provides a $500.00 stipend to each delegate/alternate.  Please save and submit all receipts to Carlene Kincaid  31 Old Barn Rd  Lenox, MA  01240 to receive the stipend.  All delegates are expected to attend and participate in the delegate’s meeting on Wednesday September 19th at the Doubletree Westborough as well as all delegate responsibilities during the 2007 ENA General Assembly in Salt lake City, Utah on September 26th and 27th.  Send this application to:  Faye Everson   64 Ebenezer Lane  Brewster, MA 02631 by July 1, 2007.