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B. CONSUMER/PROVIDER DETERMINANTS <br /> <br /> 1, (Please respond to following questions by writing Yes or no in the <br /> spaces provided.) <br /> <br /> a. Bo you hold a membership (board or other) in any health interest <br /> organization? (If yes, please specify,) <br /> <br /> b. Do you receive (either directly or through your spouse) more than <br /> one fifth of your gross annual income from any or a combination <br /> of the following: (1) fees er other compensation for research, <br /> instruction, er consdltation in the provision of health care; <br /> (5) organizations engaged in the provision of health care or in <br /> such research or instruction; or (3) producing or supplying drugs <br /> or other articles for individuals or entities for use in the <br /> research, instruction, or provision of health care; (4) entities <br /> engaged in producing drugs or such Other articles. <br /> <br /> c. Are you engaged in issuing any policy or contract or individual <br /> or group health insurance or hospital or medical service <br /> benefits? <br /> <br /> d. Are you a member of the immediate family (spouse and/or children <br /> living in same household) of a physician, dentist, nurse, podiatrist, <br /> physician assistant~ or any individual engaged in the direct pro- <br /> vision of health care services? <br /> <br /> 2. Public Official: Elected Appointed <br /> <br /> Please specify position <br /> <br /> 3. Private or Public Agency Representative ' <br /> <br /> Identify agency <br /> <br /> Name & affiliation of person making nomination if other than nominee <br /> <br /> Name (please print) Signature <br /> <br /> I~agree to serve as a member of the SPHSA Governing Body if elected to <br /> such position at the next Annual Meeting or in the interim to complete <br /> an unexpired term~ <br /> <br /> Date Signature of Nominee <br /> <br /> FOR USE BY GENERAL PURPOSE LOCAL <br /> GOVERNMENTAL UNITS (e,g. County, City, Town Governments) <br /> <br /> Should the above nominee be elected to a seat on the SPHSA Governing <br /> Body, the nomlnee (will ) (will not ) be accepted as a representative <br /> of our government jurisdiction. <br /> <br /> Signature of Person Authorized to Act for Jurisdiction <br /> <br /> <br />