GIC HIMSS Mentorship Application- Mentor

GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest

If you are interested in becoming a mentor, please complete the form below and include your CV or
resume with your response. If selected, you will be notified of the individual you will be mentoring by
the Professional Development Director. You must commit to providing guidance for the duration of
the mentorship program. Mentors are not obligated to continue the mentoring relationship past the
program, but further communication and connection is encouraged.

Question Title

* 1. Please provide the following information:

Name

Company

Email Address

Phone Number

Question Title

* 2. What is your current position within your company?

Question Title

* 3. Years of HIMSS Membership

1-5 years

5-15 years

More than 15 years

Question Title

* 4. Years of experience in Health Information Technology or Health Information Management

5-10 years

11-15 years

More than 15 years

Question Title

* 5. What are your areas of expertise?

Leadership & Management

Project Management

Data Architecture

Healthcare Analytics

Informatics

Cybersecurity

Other (please specify)

GIC HIMSS Mentorship Application- Mentor

GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest

Question Title

* 1. Please provide the following information:

Question Title

* 2. What is your current position within your company?

Question Title

* 3. Years of HIMSS Membership

Question Title

* 4. Years of experience in Health Information Technology or Health Information Management

Question Title

* 5. What are your areas of expertise?

Question Title

* 6. Please describe what you can provide to a mentee

Question Title

* 7. Please upload a recent CV or Resume

GIC HIMSS Mentorship Application- Mentor

GIC HIMSS Mentorship Program 2021-2022 Mentor Interest

Question Title

* 1. Please provide the following information:

Question Title

* 2. What is your current position within your company?

Question Title

* 3. Years of HIMSS Membership

Question Title

* 4. Years of experience in Health Information Technology or Health Information Management

Question Title

* 5. What are your areas of expertise?

Question Title

* 6. Please describe what you can provide to a mentee

Question Title

* 7. Please upload a recent CV or Resume

GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest