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BIOSKETCH AND SURVEY

* Indicates required fields

REQUEST NOT TO PUBLISH

I do NOT want any of the information provided on this Biosketch and Survey to be:
Published in the Directory of Ethnic Minority Professionals in Psychology
Disseminated as part of OEMA's Job Bank Service
If no boxes are checked, it is assumed you grant APA permission to publish and disseminate this information.

APA INFORMATION

* Are you a member of APA? Yes     No
  Your APA Membership #:
  Membership Type:
List APA Divisions that you affiliate with:
  As a FELLOW:
  As a MEMBER:

Demographic Information

* First Name:
  Middle Initial:
* Last Name:
  Institution/Company:
* Street Address:
  Street Address Cont.:
  Street Address Cont.:
* City:
* State:
* Zip Code:
  Foreign Country:
  JOB TITLE:
  Home Phone:
  Office Phone:
  FAX:
* E-MAIL:

ETHNIC/RACIAL GROUP IDENTITY:

* Check all that apply:
African American/Black American Indian/Alaska Native
Asian American/Asian/Pacific Islander Hispanic/Latino
European American/White
Other:

* GENDER:

Male   Female

NON-ENGLISH LANGUAGE FLUENCY IN:

Check all that apply.
American Sign Language Arabic
French German
Italian Japanese
Korean Portuguese
Spanish Urdu
Chinese (Dialect: )
Filipino (Dialect: )
Hindi (Dialect: )
Other (List): )

* MAJOR PSYCHOLOGICAL FIELD OF STUDY:


AREAS OF INTEREST:

Select & list 6 or fewer CODES from the "Areas of Interest Code List" (PDF)

GRADUATE DEGREES EARNED:

* Type: * Year: * Institution:
Type: Year: Institution:

CURRENT PROFESSIONAL ROLE(S):

* Rank order no more than 3 in terms of "time & effort" with 1 = Primary Role
Academician Consultant
Researcher Administrator
Practitioner
Other (Describe: )

* ARE YOU A LICENSED PSYCHOLOGIST? Yes No
State(s) of Licensure*
 *For multiple selections, hold the CTRL
    key while selecting

JOB BANK INFORMATION

PREFERRED EMPLOYMENT SETTING:

* Check all that apply.
Academia/Teaching Direct Services Delivery
Private Industry Administration
Government Research
Other ( *Describe: )

PREFERRED PROFESSIONAL ROLE(S):

* Rank order no more than 3 with 1 = Most Preferred.
Academician Consultant
Researcher Administrator
Practitioner
Other (Describe: )

PREFERRED GEOGRAPHIC LOCATION:

Check all that apply.
No geographic restrictions on place of employment.
Preferred U.S. States
AL AK AR AZ CA
CO CT DE DC FL
GA HI ID IL IN
IA KS KY LA ME
MD MA MI MN MO
MS MT NE NC NH
NJ NM NY NV ND
OH OK OR PA RI
SC SD TN TX UT
VT VA WA WV WI
WY
Preferred U.S. Possessions
American Samoa Federal States Of Micronesia
Guam Marshall Islands
Northern Marianas Islands Palau
Puerto Rico Virgin Islands

Foreign Countries
Canada Mexico
Other  

INVOLVEMENT IN ORGANIZED PSYCHOLOGY:

Please check each item that applies.
1. Are you a member of one of the national Ethnic Minority Psychological Associations (EMPA) -- i.e., AAPA, ABPsi, NLPA, or SIP?
2. Ever served as a local or national Officer or Committee Chair of an EMPA?
3. Are you a member of a State Psychological Association (SPA)?
4. Ever served as an Officer or Committee Chair of a SPA?
5. Are you a member of a Regional Psychological Association (RPA)?
6. Ever served as an Officer or Committee Chair of a RPA?
7. Ever served as an Asst., or Assoc. or Senior journal editor?
8. Ever served on an APA Task Force?
9. Ever served on an APA Committee?
10. Ever served on an APA Board?
11. Ever served on an APA accreditation site visit team?
12. Would you be willing to serve as an APA Accreditation Site Visitor?
13. Would you be willing to be a reviewer for APA journals or books?
14. Would you be willing to serve on the Editorial Board of an APA journal?
15. Would you be willing to serve on an APA Task Force, Committee or Board related to:
→ Executive Functions (e.g., convention, ethics, international issues)?
→ Education Issues (e.g., accreditation, continuing education, etc.)?
→ Practitioner Issues
→ Public Interest Issues (e.g., ethnic minorities, women, children & families, gays & lesbians, AIDS, disabilities, etc.)?
→ Science Issues (e.g., research standards, funding & ethics; testing & assessment)

ISSUES OF CONCERN FOR PSYCHOLOGISTS OF COLOR

* Rank order no more than 3 of the following, with 1 = "Highest Priority".
Culturally appropriate research methods
Culturally competent MH service delivery
Families & youth
Health Care Reform : Effects on Communities of Color
Health Care Reform: Effects on Psychologists of Color
Health Disparities
HIV/AIDS
Minority recruitment, retention & training in psychology
Professional advancement /income
Psychology and Public Policy
Public schools/education
Research funding
Substance Abuse
Testing & assessment bias
Violence prevention
Other/ *Describe:

Please Attach Your Vita
(only .pdf, .doc, & .docx allowed and no larger than 3 Megabytes)   
If you wish to mail or fax in your vita, or have questions, contact:

Sherry T. Wynn
Office of Ethnic Minority Affairs
Public Interest Directorate
American Psychological Association
750 First Street, NE
Washington, DC 20002
202/336-6029
202/336-6040 (fax)