Name Mailing Address Work Phone Home Phone Work Email Address Preferred Method of Contact Home Work Current Employer Current Position Highest Education Degree Attained Area of Concentration List all Certifications and/or Licenses Maintained Please indicate areas of interest (Please choose any areas you have interest in being involved.) CCM Item Writing Write questions, or items, for the CCM exam test bank. CCM Item Review Review questions, or items, for the CCM exam test bank. CCM Form Reviews Reviewing the exam that is offered (up to three times per year) CCM Problem Item Notification (PIN) calls: The testing administrator runs a statistical analysis of the exam scores to determine how items performed within an acceptable range. Items that perform less well statistically are flagged to be reviewed by yet another panel of SMEs during a Problem Item CCM Education Development and Review Identify and develop educational opportunities and professional development for CCMC. CDMS Item Writing Write questions, or items, for the CDMS exam test bank. CDMS Item Review Review questions, or items, for the CDMS exam test bank. CDMS Form Reviews Reviewing the exam that is offered (up to two times per year) CDMS Problem Item Notification (PIN) calls The testing administrator runs a statistical analysis of the exam scores to determine how items performed within an acceptable range. Items that perform less well statistically are flagged to be reviewed by yet another panel of SMEs during a Problem Item CDMS Education Development and Review CDMS Education Development and Review: Identify and develop educational opportunities and professional development for CDMS. Ethics and Professional Conduct Issues opinions regarding the interpretation and application of the Code of Professional Conduct for Case Managers, oversees investigations, and rules on cases involving alleged violations, maintaining strict confidentiality. Professional Development and Education Committee Conducts review and advancement of professional development and educational offerings for both disability management specialists and case managers to support certification and re-certification Certification Services Regularly review of all programs and services consistent with the Commission's mission and resources; recommending the continuation or modification of current programs; reviewing new program or service proposals and recommendations. Other Area of Interest List current professional responsibilities (Please highlight and specify financial, writing, communication, leadership responsibilities.) Relevant experience & background (Related to area of interest) List your memberships in national organizations over the past five (5) years: How did you hear about us? Referred by a Commissioner or other volunteer? Have you ever held a professional license or certification that was revoked, suspended, voluntarily relinquished, or placed on probation, or otherwise been disciplined by a professional licensure or certification body? Yes No If yes, please provide an explanation stating the facts in full I agree to disclose information about my relationship with industry to determine any actual, potential or questionable conflict of interest should that is required for this committee appointment (This is for disclosure purposes only.) Yes, I can meet the following expectations: Disclosure List Computer access and ability to receive email and download files. Fax accessibility for both sending and receiving. Ability to participate in conference calls with the possibility of limited travel. Committee assignments must be completed in a timely manner prior to conference calls and/or meetings. Most work is conducted via conference call or email. Committee appointment is for a term of one year. Approximately 40-50 hours of voluntary service is required per year. Independent and group skills required. Submit
