Board Nominations 2018

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* 1. Contact Information

First

Last

Title

Company

Address

City

Province

Postal code

Business phone

Mobile

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* 2. How long have you been a member of Digital Health Canada (previously COACH)?

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* 3. Why do you want to join the Digital Health Canada Board of Directors at this point in your career?

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* 4. How does your experience align with the Digital Health Canada strategic plan and mandate?

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* 5. What unique skills, perspectives and contributions would you bring to the Digital Health Canada Board?

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* 6. Do you or have or have you ever had any direct patient care experience (clinical)?

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* 7. What segments within the Digital Health Canada community do you feel you will best represent? Select all that apply.

Executives/CIOs

Emerging Professionals

Telehealth

Clinicians

Vendors

IM/IT Practitioners

Leaders

Academic & Research

Healthcare Institutions

National eHealth Organizations

Digital Health Entrepreneurs

Retail Health

Insurance

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* 8. With which Digital Health Canada committees, task groups or activities have you volunteered in past five years? Describe your most significant contributions to Digital Health Canada's mission.

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* 9. What other board appointments or relevant leadership experiences have you had in the past five years?

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* 10. Please tell us why you feel Digital Health Canada members should vote for you.

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* 11. Do you currently hold the Certified Professional in Healthcare Information and Management Systems – Canada (CPHIMS-CA) credential?

Yes

Committed to achieving my CPHIMS-CA

Not currently eligible to write the exam

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* 12. What is your educational background? Please list all degrees and designations.

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* 13. Please include a brief biography including highlights of experience and expertise in health informatics/digital health.

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* 14. Who is nominating you for this position? (Nominator 1 of 3)

First

Last

Company

Phone

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* 15. Nominator 2 of 3

First

Last

Company

Phone

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* 16. Nominator 3 of 3

First

Last

Company

Phone

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* 17. Nomination and Consent Form (DOWNLOAD)

The Form must be signed by the nominee and each of the three nominators. If the nominators are unable to sign the same form, they may sign a copy. All copies must be signed by the nominee. Scan completed forms and upload using the links below.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 18. Nomination and Consent Form (copy)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 19. Nomination and Consent Form (copy)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 20. Please use the link below to upload a recent portrait photo (head and shoulders) for posting on the Digital Health Canada website.

File format: JPG, JPEG, or PNG.

PDF, JPEG, JPG, PNG, GIF file types only.

Choose File