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BIOSKETCH AND SURVEY
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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: |
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| 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: |
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| 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 |
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| * 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 | ||
| If you wish to mail or fax in your vita, or have questions, contact: | ||
Sherry T. Wynn |
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