2012 AHCA / NCAL NATIONAL QUALITY AWARD STUDENT EXAMINER APPLICATION

GENERAL INFORMATION

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* 1. Experience (check all that apply)

I am a returning Quality Award Student Examiner

I am a new Quality Award Student Examiner Applicant

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* 2. Applicant Information

Name

School/University

Address

City

State

Zip

Phone

Cell Phone

Email

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* 3. Previous Employers in Health Care (Name, City/State, Years)

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* 4. Have you ever worked for an organization that received an AHCA/NCAL National Quality Award?

Yes

No

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* 5. If yes, please check which Level(s) and the corresponding year(s):

Bronze Year(s)

Silver Year(s)

Gold Year(s)

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* 6. Please describe your involvement in the preparation of the applications for these awards.