2018 Speaker Form Please complete this form to request your CSA Board Liaison to present the AHIMA Report to CSAs at your 2018 Annual Meeting. Question Title * 1. What is your CSA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Question Title * 2. Date Information Meeting Date Presentation Date for the CSA Board Liaison Question Title * 3. Who is the CSA Contact? Name E-mail Phone Question Title * 4. Meeting Location City State Name of Venue; hotel, conference center, etc. Question Title * 5. Presentation(s) requested for the meeting. AHIMA Report to CSAs Topic(s) from the CSA Excellence Series Question Title * 6. If requesting a topic(s) from the CSA Excellence Series please select from the following. Advocacy AHIMA Membership AHIMA Student Membership CCHIIM Consumer Engagement Data Analytics HIM Awareness Building HIM Reimagined Informatics Information Governance Professional Ethics Revenue Integrity Volunteer Opportunities Question Title * 7. Approximately, how many participants will attend the meeting? Question Title * 8. Please check off those you agree with. Your state will provide audio visual for the speaker Please check if your state agreed to the Forward Funding Program Honorarium as a donation to the AHIMA Foundation Done