Qualtrics Survey | Qualtrics Experience Management

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Please share your membership nomination(s) using this form. Fill out the following questions to the best of your ability. Our staff team will work to fill in any gaps in the information.

Nominee Name

Nominee Email

Which best describes the nominee's gender identity?

Female
Male
Non-binary / gender queer
Transgender
Unsure
Other

Is the nominee Hispanic or Latinx?

Yes
No
Not sure

Nominee's race/ethnicity

American Indian or Alaskan native
Asian
Black
Native Hawaiian or Other Pacific Islander
White
Hispanic
Other

Select the nominee's age range

Under 18
18–24
25–34
35–44
45–54
55–64
65+
Prefer not to answer

Does the nominee identify as a person with a disability? (This question is optional)

Yes
No
Prefer not to answer
I don't know

Does the nominee identify as a military veteran?

Yes
No
Prefer not to answer
I don't know

Does the nominee know they are being nominated?

Which of the following best describes their area of expertise? This is lived, scholarship, or professional expertise. (Based off of community priorities in 2019 Working Group Report)

University-Community Relations
Jobs and Wages
Youth, Schools, Child Care
Business and Finance, Non- Profits
Housing, Planning, Public Spaces
Law Enforcement and Community Policing
Immigration
Food Security
Public Health
Historical Truth Telling
Transportation
Community Safety
Other:

Nominee Category

Community Member (Do not work for UVA)
University Faculty
University Staff
University Graduate Student
University Undergraduate Student

Which of the following communities within the Blue Ridge District does the person work with?

Albemarle County
Charlottesville City
Fluvanna County
Greene County
Louisa County
Nelson County
All the above
Other:

In which community does this individual live?

Albemarle County
Charlottesville City
Fluvanna County
Greene County
Louisa County
Nelson County
All the above
Other:

Please briefly describe why you recommend this person for membership on the Council, referencing the criteria listed in the Council Charter. Please include examples that speak to this individual's tangible impact in the community.

If applicable, please add any links or articles that exist that describes the nominees work. Please include references to awards, acknowledgements, or other forms of recognition this individual has received.

Submitter Name