2027 THA Leadership Fellows Application

Biographical Information

Question Title

1. Name (Required.)

Question Title

2. Degrees (Required.)

Question Title

3. Designations (Required.)

Question Title

4. Title (Required.)

Question Title

5. Company/Organization Name (Required.)

Question Title

6. Address (Required.)

Question Title

7. Phone Number (Required.)

Question Title

8. Email (Required.)

Question Title

9. Current Position by General Role (Required.)

CEO/Administrator

CNO

CFO

CIO

CMO

CIC

Physician

Trustee

Director-Level

Other (please specify)

Question Title

10. Hospital Owership (Required.)

Investor-Owned

Public/Government-Owned

Not-for-profit

Partnership

Question Title

11. Hospital Type (Required.)

Urban

Rural

Suburban

Critical Access

Academic Medical Center

Other (please specify)

Question Title

12. Hospital Size (Required.)

Under 100 Beds

101-500 Beds

500+ Beds

Question Title

13. Please select your gender identity (Required.)

Female

Male

Transgender

Genderqueer/gender non-conforming

Other (please specify)

Question Title

14. Age (Required.)

26 or under

27-40 years old

41-57 years old

58-75 years old

75+ years

Question Title

15. Race and Ethnicity (*Options determined based on proposed U.S. Census categories). May select multiple categories (Required.)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Other (please specify)

Page1 / 5

20% of survey complete.

2027 THA Leadership Fellows Application

Question Title

* 1. Name (Required.)

Question Title

* 2. Degrees (Required.)

Question Title

* 3. Designations (Required.)

Question Title

* 4. Title (Required.)

Question Title

* 5. Company/Organization Name (Required.)

Question Title

* 6. Address (Required.)

Question Title

* 7. Phone Number (Required.)

Question Title

* 8. Email (Required.)

Question Title

* 9. Current Position by General Role (Required.)

Question Title

* 10. Hospital Owership (Required.)

Question Title

* 11. Hospital Type (Required.)

Question Title

* 12. Hospital Size (Required.)

Question Title

* 13. Please select your gender identity (Required.)

Question Title

* 14. Age (Required.)

Question Title

* 15. Race and Ethnicity (*Options determined based on proposed U.S. Census categories). May select multiple categories (Required.)

1. Name (Required.)

2. Degrees (Required.)

3. Designations (Required.)

4. Title (Required.)

5. Company/Organization Name (Required.)

6. Address (Required.)

7. Phone Number (Required.)

8. Email (Required.)

9. Current Position by General Role (Required.)

10. Hospital Owership (Required.)

11. Hospital Type (Required.)

12. Hospital Size (Required.)

13. Please select your gender identity (Required.)

14. Age (Required.)

15. Race and Ethnicity (*Options determined based on proposed U.S. Census categories). May select multiple categories (Required.)