OHA EMS & Trauma Systems Stroke Committee Application

Demographic Information

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By what name do you prefer to be called? (e.g. Thomas --> Tom, Cynthia --> Cindy)

P.O. Box, if appropriate

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Phone
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Phone

Position Interest

List the agency you represent.    

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Supporting Documents

Will you be uploading a Letter of Interest (LOI)?

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Please provide an explanation of your interest and relevant experience to support serving on this committee for the OHA EMS & Trauma Systems program. Put N/A if you choose to submit a document instead of writing a response here. *A LOI IS REQUIRED TO BE CONSIDERED FOR APPOINTMENT TO THE COMMITTEE.*

Will you be uploading a Resume/CV?

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Upload your Letter of Interest (LOI), if appropriate, and upload a resume or CV that includes your experience and expertise to support your role on the committee. *A RESUME OR CV IS REQUIRED TO BE CONSIDERED FOR APPOINTMENT TO A COMMITTEE.* ** If you are unable to upload the document, please, submit your resume or CV to EMS.TRAUMA@dhsoha.state.or.us.

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Equal Opportunity Questions (Optional)

* To better assist us in meeting our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against anyone.

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* To better assist us in meeting our affirmative action objectives, we would appreciate information about your background and gender identity. This information is optional and is used for data collection only. Under state and federal law, this information may not be used to discriminate against anyone.

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