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2011 AHCA / NCAL National Quality Award Senior/Master Examiner Application

Applicant Role
1. APPLICANT INFORMATION
Contact Information:
Type of organization:
Please list your previous employers in long term care (Name, City, State, Years):
Have you ever worked for an organization that received an AHCA/NCAL National Quality Award?
If yes, please enter the year(s) in which your facility/organization received the corresponding award(s):
Please describe your involvement in the preparation of the applications for these awards:
2. EXPERIENCE
In 200 words or less, please describe your experience in long-term care quality improvement. Also describe any involvement with Baldrige-based or other criteria-based award programs, including your state’s quality award program, if applicable. Please list any relevant certifications.

3. REFERENCES

Please provide contact information for two references who are familiar with your skills, knowledge, and experience in long-term care and quality improvement.
Reference 1:
Reference 2:
3. PUBLICITY RELEASE
AHCA/NCAL publicizes the names of examiners in printed materials and at events. Do we have your permission to publicize your name?
4. LEVEL OF COMMITMENT
If I am selected to serve as a Quality Award Examiner in 2011:
Yes
No
N/A
I will attend a one-day team leader training session in March (team leader applicants only):
I will participate in all webinar-based Examiner training sessions (note: webinars are recorded and can be accessed at any time):
I will participate in weekly conference calls with my Examiner team members during the 8-week Examination period:
I will participate in the 3-4 day on-site review session scheduled for the week of May 16, 2011:
I will participate in the 3-4 day on-site review session scheduled for the week of May 16, 2011:
I have the support of the leadership at my organization to serve as an Examiner (if currently employed):
I have read and understand the Quality Award Examiner Code of Ethical Standards:

AHCA/NCAL National Quality Award - Quality Award Examiner Code of Ethical Standards

Declaration of Principles

As a member of the AHCA/NCAL National Quality Award Board of Senior Examiners, I pledge to uphold professional principles in the fulfillment of the responsibilities associated with this position, including the promotion of high standards of public service and ethical conduct.

Board Members:

  • Shall conduct themselves professionally, with truth, accuracy, fairness, and responsibility;
  • Shall not represent conflicting or competing interests, nor place themselves in such a position where the members’ interest may be in conflict, or appear to be in conflict, with the purposes and the administration of the Award;
  • Shall not offer confidential information or disclosures which may in any way influence Award integrity or process, currently or in the future;
  • Shall not serve any private or special interest in fulfillment of the duties of an Examiner, therefore excluding, by definition, the examination of any company, division, or business unit of which he/she is employed or of which a consulting arrangement is in effect or anticipated;
  • Shall not serve as an Examiner of a primary competitor, customer, or supplier of any company, division, or business unit of which he/she is an employee, holds stock or is involved in, or anticipates, a consulting arrangement;
  • Shall not intentionally communicate false or misleading information which may compromise the integrity of the Award process or decisions therein;

Furthermore, it is pledged that as a member in good standing of the AHCA/NCAL National Quality Award Board of Senior Examiners, each Board member shall endeavor to aid the professional development and advancement of the AHCA/NCAL National Quality Award as it serves to stimulate American companies to improve quality and productivity through improved quality management.