Prospective Board Member Application Form

Prospective Board Member Application Form

Confidential - Please provide the following information for consideration by the Governance Committee.
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The Health Resources and Services Administration's (HRSA) specific regulations for Federally Qualified Health Centers (FQHCs) prohibit employees and their family members from serving as governing board members.
Are you or any immediate family member an employee of One Community Health?

YesNo

Current Job Title:
Professional Skills:
Type of Work Experience:
Special Interests:
Education:
Please describe your leadership/or volunteer experience, listing any positions held or organizations where you have volunteered:
Area(s) of expertise and/or contributions you feel you can make at One Community Health as a Board Member:
Other volunteer commitments you have made:
Do you or does any member of your immediate family (domestic partner, spouse, children, parents, in-laws) have a “relationship” (work, consulting, income, contractual agreement, affiliation, board membership or other interest) with any of the following?

Hospital/medical center/nursing home/home health/pharmacy/other health care organization or clinicSupplier of goods to health center or medical groupHealth insurance company or HMO, PPOLaw firmBoard member of another organizationOther healthcare related organization
Please specify the industry and list the nature of the relationship:

Are you a patient of One Community Health?

YesNo
Have you had a visit within the past 24 months?

YesNo
Do you feel you represent an OCH patient group or special population we serve? (migrant seasonal farmworker, Native American, other)
What motivates you to volunteer for a health care board of directors?
Which parts of One Community Health’s mission or work inspires you? (e.g., our value: we recognize the importance of caring for people who face barriers in accessing services because they have difficulty paying for services or because they have language or cultural differences and disparities in their health status.)
How much time do you have available for One Community Health Board service?
What expectations do you have from the management of One Community Health on whose board you would serve?
Do you have personal aspirations that could be enhanced by service on our board? (As an advocate; marketing; speaking on behalf of center, etc.)
Do you anticipate any professional or personal constraints on your time or service as a volunteer board member?
Is social interaction with other board members important to you?
How do you feel the performance of a Board should be evaluated?
Do you see yourself as an ambassador and advocate? Would you consider actively advocating on behalf of OCH’s strategic goals to others locally or at the state level?
Is there anything else you would like to tell us about yourself?

By clicking 'Submit,' you confirm that you or an immediate family member is an employee of One Community Health. As a Federally Qualified Health Center (FQHC), HRSA guidelines prevent employees or their immediate family members from serving on our governing board.
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