The members of the Ethics Committee would like to thank you for your interest in serving OPA. Below are a few questions that would allow us to know more about your interests and qualifications. You may need to provide some answers on a separate sheet.

We require that members of the committee be licensed for a minimum of 10 years because of the significant amount of professional responsibility required in the work we do. However, one or two early career psychologists may sit on the committee for the purpose of obtaining Ethics Committee experience. Early career psychologists must be licensed for a minimum of 5 years, and these individuals will not vote on issues or be listed on the website. They may attend meetings but may not provide consultation regarding ethics cases.

Ethics Committee involvement requires a minimum three-year commitment that is renewable. If our committee is full we would like to keep your information on file for future reference. Also note that Ethics Committee members are required to have at least 6 hours of ethics CE per year.

Please complete the applicable fields below to change your address on file with OPA.  Items marked with a * are required.

Name and Credential*:       

License Number*:            Year Licensed*:            Number of years in practice*:       

Address*:

City, State, Zip*:       

E-mail*:       

Home phone*:   

Website:

How many hours of ethics CE have you had in the last 3 licensing cycles?
 
   2000-2002*
   2002-2004*
   2004-2006*

Place of employment*:     

Employment setting*:     

Provide a brief resume that describes your work (e-mail to Richard Ashbrook, Ph.D.)*.

What are your areas of specialization?*  

What diversity would you bring to the committee?*        

What is your interest in being on this committee?*       

Have you ever served as a committee member on local, state or national committee?*        

What do you feel qualifies you for serving on the Ethics Committee?*       

Have you ever had a complaint filed about you with the State Board of Psychology?*        Yes      No
    If yes, what was the charge and what was the resolution?

Have you ever been the subject of a professional liability claim?*        Yes        No
    If yes, what was the nature of the claim and what was the resolution?

Have you ever been asked to resign from any hospital, healthcare organization or managed care organization?*        Yes        No
    If yes, please explain.

List two professional references and a phone number for each*

Reference #1*
Name      Phone (include area code)  

Reference #2*
Name      Phone (include area code)  

Reminder: Provide a brief resume that describes your work (e-mail to Richard Ashbrook, Ph.D.)*.

Questions?  Contact OPA Ethics Committee Chair Richard Ashbrook, Ph.D. at 614-291-7600 (or Fax: 614-291-3800).