2019-20 KHSC Board of Directors - Application Form

Hotel Dieu and Kingston General Hospitals have integrated to form the Kingston Health Sciences Centre. We are currently seeking interested members of our community and region to serve on the board of directors.

Applications can be received on-line, by mail, fax or e-mail.

Mail: Kingston Health Sciences Centre - KGH Site, 76 Stuart Street, Watkins 2, Kingston, K7L 2V7

Fax: 613-549-6707

Email: KHSCceo@kingstonhsc.ca

If you have questions regarding the application process, please call us at 613-548-6002.

If you are submitted your application on-line, it is important to note that most information transmitted over the internet is not secure, therefore, confidentiality cannot be guaranteed. The following form has been created on SurveyMonkey using cloud-based software and the information is housed in the United States. U.S. privacy laws would govern this information. Your application will only be kept on the site until the selection process has been completed.

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* 1. Name

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* 2. Business Address

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* 3. Home Address

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* 4. Contact phone numbers and email

Business phone:

Home phone:

Cell phone:

Email address:

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* 5. Preferred method of contact

Home number

Business number

Cell number

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* 6. Additional information

Anglophone

Francophone

Other languages spoken / written (please specify)

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* 7. I can confirm that I have board/executive experience and expertise in:

Chartered / professional accountant designation

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* 8. The Governance Committee seeks a complementary balance of knowledge, skills and experience. Please indicate your areas of knowledge, skills and experience by completing the following listing or by simply listing your skills in the other box and the end of this question.

	Basic	Intermediate	Advanced
Board & Governance	Board & Governance Basic	Board & Governance Intermediate	Board & Governance Advanced
Clinical	Clinical Basic	Clinical Intermediate	Clinical Advanced
Construction & Project Management	Construction & Project Management Basic	Construction & Project Management Intermediate	Construction & Project Management Advanced
Diversity	Diversity Basic	Diversity Intermediate	Diversity Advanced
Education	Education Basic	Education Intermediate	Education Advanced
Ethics	Ethics Basic	Ethics Intermediate	Ethics Advanced
Finance	Finance Basic	Finance Intermediate	Finance Advanced
Governance & Government Relations	Governance & Government Relations Basic	Governance & Government Relations Intermediate	Governance & Government Relations Advanced
Health Care Administration & Policy	Health Care Administration & Policy Basic	Health Care Administration & Policy Intermediate	Health Care Administration & Policy Advanced
Human Resources/Talent Management	Human Resources/Talent Management Basic	Human Resources/Talent Management Intermediate	Human Resources/Talent Management Advanced
Patient & Health Care Advocacy	Patient & Health Care Advocacy Basic	Patient & Health Care Advocacy Intermediate	Patient & Health Care Advocacy Advanced
Political Acumen	Political Acumen Basic	Political Acumen Intermediate	Political Acumen Advanced
Patient & Health Care Advocacy	Patient & Health Care Advocacy Basic	Patient & Health Care Advocacy Intermediate	Patient & Health Care Advocacy Advanced
Quality & Performance Management	Quality & Performance Management Basic	Quality & Performance Management Intermediate	Quality & Performance Management Advanced
Research	Research Basic	Research Intermediate	Research Advanced
Risk Management	Risk Management Basic	Risk Management Intermediate	Risk Management Advanced
Stakeholder Engagement	Stakeholder Engagement Basic	Stakeholder Engagement Intermediate	Stakeholder Engagement Advanced
Strategic Planning	Strategic Planning Basic	Strategic Planning Intermediate	Strategic Planning Advanced

Other (please specify)

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* 9. Please list current or prior board experience

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* 10. Which areas of board work are of particular interest to you?

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* 11. Please describe linkages you have or may have had with other health care organizations in the community or region.

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* 12. Conflict of Interest Disclosure Statement
Directors must avoid conflicts between their self-interest and their duty to the Kingston Health Sciences Centre. In the space below, please identify any relationships with any organization that may create a conflict of interest, or the appearance of a conflict by virture of being appointed to the board.

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* 13. Declaration Requirements

Applicants are required to review several important documents located on our website to support the application process.

By submitting this application, I declare that I have read the documents noted below and I accept the conditions as outlined. I certify that the information in this application and provided in my resume or bio sketch is accurate.

Board Policy - Process for Nomination of Directors

Board Policy - Position Description - Board of Directors

Board Policy - Code of Conduct

Board Policy - Conflict of Interest

Board Policy - Confidentiality

Board Policy - Board Orientation

Board Policy - Board & Committee Attendance

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* 14. Resume / Bio Sketch

Will be emailed to: KHSCceo@kingstonhsc.ca

Will be faxed to: 613-549-6707

Will be mailed to: Kingston Health Sciences Centre, CEO Office, 76 Stuart Street, Watkins 2, Kingston, K7L 2V7

2019-20 KHSC Board of Directors - Application Form

Question Title

* 1. Name

Question Title

* 2. Business Address

Question Title

* 3. Home Address

Question Title

* 4. Contact phone numbers and email

Question Title

* 5. Preferred method of contact

Question Title

* 6. Additional information

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* 7. I can confirm that I have board/executive experience and expertise in:

Question Title

* 8. The Governance Committee seeks a complementary balance of knowledge, skills and experience. Please indicate your areas of knowledge, skills and experience by completing the following listing or by simply listing your skills in the other box and the end of this question.

Question Title

* 9. Please list current or prior board experience

Question Title

* 10. Which areas of board work are of particular interest to you?

Question Title

* 11. Please describe linkages you have or may have had with other health care organizations in the community or region.

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* 14. Resume / Bio Sketch

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* 15. Today's date