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2024/2025 AHCA Committee Nominations

Please select the committee for which you would like to nominate an individual or yourself. Please be sure to review the committee descriptions before making a nomination to learn about the work and responsibilities expected of the committee members. For a list of committee descriptions, see this page. In an effort to create diverse and widespread representation, each committee may be limited to one participant per state and company. All 2024/2025 Committee Appointments will be for a two-year term. Please complete a new Survey Monkey if you would like to be considered for more than one committee.

Question Title

* 1. Nominator Information (If different from nominee)

First Name

Last Name

State

All questions from this point forward are about the nominee

Question Title

* 2. Nominee Information

First Name

Last Name

Title

Company

Company Mailing Address

City

State (Example: DC)

Zip Code

Work Phone (Please use ###-###-#### format)

Question Title

* 3. Nominee Race

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

Other (please specify)

Question Title

* 4. Nominee Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Question Title

* 5. Nominee Gender

Question Title

* 6. Company Type (Select One)

Long Term Care Provider

Vendor/Associate Business Member (NOTE - Vendor/ABMs should not complete this survey monkey. There is a seperate process. Contact Hannah Gallagher at hgallagher@ahca.org for more information.

State Affiliate Office

Other Association

Consultant

Other (please specify)

Question Title

* 7. AHCA/NCAL Member

Yes

Question Title

* 8. Long Term Care Facility Type (check all that apply)

Nursing Home

Assisted Living/Residential Care

Sub-acute Care

ID/DD

Continuing Care Retirement Community

Not Applicable

Other (please specify)

Question Title

* 9. For profit/Not for profit status

For profit

Not for profit

Question Title

* 10. Does the nominee own skilled nursing or assisted living centers?

Yes

Question Title

* 11. Please select the committee you would like to nominate the individual or yourself. To create diverse and widespread representation, each committee may be limited to one participant per state and company. Please complete a new Survey Monkey if you would like to be considered for more than one committee.

The following committees are NOT included in this process: Council for Post Acute Care, Quality Cabinet, Population Health Management Council and Reimbursement Cabinet