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The ICEP Committee Application for the 2019-2020 cycle is open now through July 1. Selections will be announced by mid-August, with committee terms officially commencing at the end of August 2019l

All current committee members must reapply if they wish to remain on their committee(s).

1. First Name: *This question is required.

2. Last Name: *This question is required.

3. Email: *This question is required.This question requires a valid email address.

4. Are you currently serving on a committee? *This question is required.

Yes

No

On which committee(s) are you currently serving? *This question is required.

Awards/Nominating

Bylaws

Educational Meetings

EM Board Review Intensive Course

EMS

Finance

ITLS Illinois Advisory

Membership

Patient & Physician Advocacy

Practice Management

Research

Social Emergency Medicine

5. Do you wish to serve on any committees for the 2019-2020 cycle? (If yes, you will specify your preferences in the next question)*This question is required.

Yes

No, please remove me from all ICEP committees

Please rank your top 3 committee choices in order of preference from most interested to least interested: *This question is required.Note: for the following table each column is restricted to a single answer across all rows.

1

2

3

Awards/Nominating

Rank Awards/Nominating as 1 out of 3

Rank Awards/Nominating as 2 out of 3

Rank Awards/Nominating as 3 out of 3

Bylaws

Rank Bylaws as 1 out of 3

Rank Bylaws as 2 out of 3

Rank Bylaws as 3 out of 3

Educational Meetings

Rank Educational Meetings as 1 out of 3

Rank Educational Meetings as 2 out of 3

Rank Educational Meetings as 3 out of 3

EM Board Review Intensive Course

Rank EM Board Review Intensive Course as 1 out of 3

Rank EM Board Review Intensive Course as 2 out of 3

Rank EM Board Review Intensive Course as 3 out of 3

EMS

Rank EMS as 1 out of 3

Rank EMS as 2 out of 3

Rank EMS as 3 out of 3

ITLS Illinois Advisory

Rank ITLS Illinois Advisory as 1 out of 3

Rank ITLS Illinois Advisory as 2 out of 3

Rank ITLS Illinois Advisory as 3 out of 3

Membership

Rank Membership as 1 out of 3

Rank Membership as 2 out of 3

Rank Membership as 3 out of 3

Patient & Physician Advocacy

Rank Patient & Physician Advocacy as 1 out of 3

Rank Patient & Physician Advocacy as 2 out of 3

Rank Patient & Physician Advocacy as 3 out of 3

Practice Management

Rank Practice Management as 1 out of 3

Rank Practice Management as 2 out of 3

Rank Practice Management as 3 out of 3

Research

Rank Research as 1 out of 3

Rank Research as 2 out of 3

Rank Research as 3 out of 3

Social Emergency Medicine

Rank Social Emergency Medicine as 1 out of 3

Rank Social Emergency Medicine as 2 out of 3

Rank Social Emergency Medicine as 3 out of 3

Appointments to the Finance Committee are determined by the ICEP Board of Directors. You will be notified if you have been invited to this committee for 2019-2020.

6. Why are you interested in serving as a committee member? *This question is required.