2019 Committee & Task Force Application

Please complete this survey by January 1, 2019. If you have any questions, please contact us at ahe@aha.org or 312-422-3860.

We will reach out to you regarding committee selections in mid-January.

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* 1. Last Name:

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* 2. First Name:

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* 3. Full Name, Including Credentials, As You Wish it to Appear on AHE Materials:

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* 4. AHE Member Number:
(This number may be found by logging into your ahe.org account or by calling us at 312-422-3860)

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* 5. Degree(s) and Certification(s):

CHESP

M-CHEST

T-CHEST

BA/BS

MPH

MBA

MA, MS, or other Master's Degree

RN or BSN

PhD

CMIP

Other (please specify)

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* 6. Organization:

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* 7. Job Title:

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* 8. Mailing Address:

Address 1: *

Address 2:

Address 3:

City/Town: *

State/Province: *

ZIP/Postal Code: *

Country: *

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* 9. E-Mail Address:

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* 10. Phone Number:

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* 11. Cell Phone Number (optional):

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* 12. AHE Membership Category:

Other (please specify)

2019 Committees

Advisory Council Assist members and staff with daily challenges of the ES profession, assist with operational aspects of executing the strategic plan, identify potential partnerships/collaborations, and provide feedback on regulatory and guidance issues as needed.

Education and Knowledge Management Committee Continuously assess the educational and professional development needs of the membership. Develop and deliver educational products, including courses, training's, publications, products, and services.

Industry Advisory and Innovations Task Force Provide AHE with a voice and support of industry, with the goal of mutually beneficial outcomes.

Nominating Committee Recommend and evaluate a slate of candidates for the Board of Directors.

Recognition Task Force To recognize AHE members for their individual contributions to caring for the health care environment and to promote recognition activities within the membership community.

*Committee appointments are typically for one year, beginning in January. Committee charges will be developed by the individual committees during their first meetings.

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* 13. Please select the committee(s) on which you would like to serve from the list below. If choosing more than one, please rank your preference by selecting 1st, 2nd, or 3rd choices (please do not select more than three choices).

Please note that the Advisory Council and Nominating Committee are by invitation-only. If you are interested in being considered, please also see Question 17.

Education and Knowledge Management

Industry Advisory and Innovation Task Force (2 slots available for PAM members)

Recognition Task Force

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* 14. Some members choose to be active on more than one committee. If you ranked more than one committee in Question 14, please let us know how many you'd like to participate on:

I would only like to participate on one committee, preferably my first choice.

I would like to participate on two committees, preferably my first two choices.

I would like to participate on three committees.

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* 15. Please indicate if you are interested in serving as a committee chair or co-chair.

I am interested in serving as a committee chair

I am interested in serving as a committee co-chair

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* 16. I am interested in being considered for appointment to the Advisory Council or Nominating Committee (Interviews and references will be required):

Yes, to the Advisory Council

Yes, to the Nominating Committee (4 slots available for PAM members who have served on other committees in the last 3 years)

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* 17. There are additional opportunities for AHE member involvement beyond serving on committees. Please indicate below if you have an interest in any of the following:

Article Contributor (HFM, and others)

Subject Matter Expert (Publications and other content needs)

LinkedIn Discussion Leader (One per month)

Exchange 2018 On-Site Volunteer (Exchange volunteers will be contacted in Summer 2018)

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* 18. Please indicate any specific qualifications for selected role(s):

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* 19. Please indicate why you are interested in serving in this role(s):

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* 20. Please let us know your past history volunteering with the AHE.

I have served on an AHE Committee in the past 3 years.

I have chaired an AHE committee in the past 3 years.

I currently serve on the committee of another organization. (Please specify in Question 21, below)

I currently chair a committee of another organization. (Please specify in Question 21, below)

I have volunteered with AHE at the Exchange conference.

I have submitted articles, facilitated courses, or served as a Subject Matter Expert for the AHE.

This is my first time volunteering with the AHE.

Other (please specify)

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* 1. Last Name:

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* 2. First Name:

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* 3. Full Name, Including Credentials, As You Wish it to Appear on AHE Materials:

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* 4. AHE Member Number: (This number may be found by logging into your ahe.org account or by calling us at 312-422-3860)

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* 5. Degree(s) and Certification(s):

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* 6. Organization:

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* 7. Job Title:

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* 8. Mailing Address:

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* 9. E-Mail Address:

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* 10. Phone Number:

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* 11. Cell Phone Number (optional):

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* 12. AHE Membership Category:

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* 14. Some members choose to be active on more than one committee. If you ranked more than one committee in Question 14, please let us know how many you'd like to participate on:

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* 15. Please indicate if you are interested in serving as a committee chair or co-chair.

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* 16. I am interested in being considered for appointment to the Advisory Council or Nominating Committee (Interviews and references will be required):

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* 17. There are additional opportunities for AHE member involvement beyond serving on committees. Please indicate below if you have an interest in any of the following:

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* 18. Please indicate any specific qualifications for selected role(s):

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* 19. Please indicate why you are interested in serving in this role(s):

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* 20. Please let us know your past history volunteering with the AHE.

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* 21. Please list the committee and position held for organizations outside of the AHE, if applicable.

* 4. AHE Member Number:
(This number may be found by logging into your ahe.org account or by calling us at 312-422-3860)