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~. CONSUMER/PROVIDER DETERMINANTS 1. [Please respond to the following questions by writing yes or no in tile spaces provided.] --- (A) Are you a direct provider of health care (including a physician, dentist, nurse, podiatrist, optometrist, physician assistant, or ancillary personnel employed under the supervision of a physician) in that your primary current activity is the provision of health care to individuals or tile administration of facili- ties or institutions (including hospitals, long-term care facilities, rehabi.litation facilities, alcohol and drug abuse treatment facilities, outpatient facilities, and health maintenance organizations) in which such care is provided and, when required by State law, you received professional training in the provision of such care or in such administration and are licensed or certified for sL~ch provision or administration; if yes, please specify: (B) Do you receive (either directly or through your spouse) more than one-fifth of your gross annual inc~ne from any one or combinatio~ of -- (1) fees or other compensation for research into or instruction in the provision of health care; (2) entities engaged in the provision of health care or in research or instruction in the provision of health care; (3) producing or supplying drugs or other articles for individuals or entities for use in tile pro- vision of or ~n research into or instruction in the provision of health care; or (4) entities engaged in producing drugs or such other articles; (C) Oo you hold a fiduciary position with, or have a fiduciary interest in, any entity described in (2) or (4) of B above; if yes, please specify: (O) Are you a member of the immediate family (spouse and/or children living in the same household) of an individual described in (A), (B), or (C) above; (E) Are you engaged in issuing any policy or contract of individual or group health insurance or hospital or medical service benefits. 2. Public Official: Elected Appointed Please specify position 3.Private or Public Agency Representative Identify ag.~ncy Name and affiliation of person making nomination, if other than nominee: N~e '~please print] Signature I agree to serve as a member of the SPHSA Governing Body if elected to such position at tile next Annual Meeting or in the interim to complete an unex- pired term. Date Signature of Nominee FOR USE BY GENERA[ PURPOSE LOCAL GOVERNMENTAL UNITS [e.g., County, City, Town Governments] Should the above nominee be elected to a seat on tile SPHSA GoveFning Body, the n~tnee (will ) (will not ) be accepted as a representative of our government 3urls~diction. '--S]-]-~tUre of Person Authorized to Act for Jurisdiction