2013 AHCA/NCAL National Quality Award Board of Overseers Application Form Survey

Name:
Position:
Organization/Parent Company (if applicable):
Time in this position:

Brief summary of your responsibilities:

Type of Organization:

Type of Organization: Nursing Facility

Assisted Living Facility

Residential Services for MR/DD

QIO

Consultant

Healthcare Provider other than NF/SNF/ALF

Other (please specify)

Organization Information:

Organization Information: Address
City
State
ZIP
Email

Have you ever served as an Examiner for the AHCA/NCAL National Quality Award?

Have you ever served as an Examiner for the AHCA/NCAL National Quality Award? Yes

No

If yes, please select which type of examiner:

If yes, please select which type of examiner: Senior Examiner

Master Examiner

List the corresponding year(s)

Have you ever served as an Examiner for the Baldrige National Quality Award or related State level awards?

Have you ever served as an Examiner for the Baldrige National Quality Award or related State level awards? Yes

No

If yes, please select which type of award program:

If yes, please select which type of award program: State Level Examiner:

National Level Examiner:

List the corresponding year(s) and State, if applicable.

2013 AHCA/NCAL National Quality Award Board of Overseers Application FormExit this survey