2018-2019 Committee Application Question Title * Indicate the Committee you are serving on: Academic Hospitalist Committee Annual Meeting Committee Chapter Support Committee Digital Learning Task Force Education Committee Hospital Quality & Patient Safety Committee Membership Committee Patient Experience Committee Performance Measurement and Reporting Committee Physicians in Training Committee Practice Analysis Committee Practice Management Committee Public Policy Committee Research Committee Question Title * Participation on SHM committees is a membership privilege. If you are not a current SHM member, you will be asked to become one if you are invited to serve on the committee. I am an SHM member I am not an SHM member, but understand that I must join SHM if I am invited to serve on a committee. Question Title * What is your first name? Question Title * What is your last name? Question Title * What is your e-mail? Question Title * On appointment to a volunteer position with SHM, all Directors, Officers, Editors, and members of all Committees shall complete this statement and update yearly or as necessary. Potential conflicts may include relationships with any of the following:Pharmaceutical, Device, Publishing, Software, Billing, Recruitment CompaniesEditorial Boards, Staff, Ownership, Authors of Publishers,Course Directors, Speakers, Ownership of MeetingsRecipients of Industry, Foundation, Government, or University GrantsDirectors, Speakers, or Editors at other OrganizationsSupport of Political Candidates or Membership in PACsMalpractice/Liability Expert Witnessing/Case ReviewDo you have any potential disclosures? Yes No Next
