HIMSS Committee Application

Required Qualifications:

· HIMSS individual member or HIMSS corporate complementary member for more than the past 12 consecutive months

· Not currently serving in a leadership position,

· Not currently serving on a HIMSS Steering Committee/Committee

Those interested in becoming involved, but not ready to apply for a Committee appointment may wish to consider joining a Task Force or Work Group.There is no application process for a Task Force or Work Group. Visit www.himss.org and contact the appropriate staff member.

Thank you for your interest in HIMSS!

I am applying for membership in the following Committee(s) *:
(Check all that apply)

Steering Committees Advocacy & Public Policy Steering Ambulatory IS Steering Enterprise IS Steering Financial Systems Steering Healthcare Information Exchange Steering Patient Safety & Quality of Care Steering Personal Health Record Steering Privacy & Security Steering	Committees Individual Membership Committee MS-HUG Advisory Committee Nursing Informatics Committee Physicians' Committee CPHIMS Technical¹ Committee Applicants must identify themselves as having expertise in one of the following: Information Systems Clinical Systems Management Engineering
¹Applicants must hold a current CPHIMS credential.

Last Name *

First Name *

Middle Name

Designation
(Use the Ctrl key to select multiple)

Work Site (Choose One)

Principal Work focus (Check all that apply)

Biomedical Engineering
Clinical Systems
Financial Management
Internet/Intranet
Leadership Management
Medical Staff Service
Reengineering/Performance Improvement
Teaching, Research

Case Management
E-Commerce/E-Health
Information Management
IT Infrastructure
Legal Aspects of Healthcare
Quality/Outcomes
Security/Confidentiality/Privacy
Telecommunications

Organization *

Title *

Professional Degree(s)

Organization Address:

Street Address, PO Box, Suite or Floor *

City *

State/Province *

Zip/Postal Code *

Phone *

Fax

Email *

Are you currently serving in a volunteer capacity for HIMSS and/or HIMSS Chapter?

- If so, please indicate role:

Have you previously served in a volunteer capacity for HIMSS and/or a HIMSS Chapter?

   - If so, please indicate role(s)
    and date(s) of service:
    (Limit of 1,000 characters)

Please describe why you believe you should be appointed to this committee and describe relevant background:
(Limit of 5,000 characters)

Please provide 3 professional references who can tell us about you:

Reference #1

Last Name *

First Name *

Middle

Phone *

Title/Organization

Email *

Relationship to Reference *

Reference #2

Last Name *

First Name *

Middle

Phone *

Title/Organization

Email *

Relationship to Reference *

Reference #3

Last Name *

First Name *

Middle

Phone *

Title/Organization

Email *

Relationship to Reference *

* Indicates a required field.

Information About the Member Application Process

Receipt of all applications will be acknowledged by mail and/or email.
Committee appointments are performed by the Chair-Elect of the HIMSS Board of Directors with input from the existing Committee Leadership Team.
All candidates will be notified by mail and/or email of the decision of the Chair-Elect. Candidates not selected for a Committee appointment will be provided with one or more opportunities to serve on a Task Force, Work Group, or Roundtable.

Additional questions about the application and selection process can be directed to Joan Flagg, Executive Assistant to the EVP at (734) 477-0862

UPON SUBMISSION OF YOUR APPLICATION, YOU SHOULD RECEIVE AN AUTO-REPLY CONFIRMATION. IF YOU DO NOT, PLEASE CONTACT JOAN FLAGG AT 734-477-0862 OR JFLAGG@HIMSS.ORG.