KHIMA Distinguished Member NominationKHIMA Distinguished Member Nomination Nominee InformationName * Name Name Name Email * Phone * Address * Address Address Address Address Address State Alabama Alaska Arkansas Arizona 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Years in HIM * Job Title (most recent or highest earned) * Highest Degree Earned Additional licenses or certifications Nominator InformationName * Name Name Name AHIMA ID Number * Email * Phone * Address * Address Address Address Address Address State Alabama Alaska Arkansas Arizona 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Address Leadership Roles Local Level * State Level * National Level * Other Affiliated Associations Impact on HIM Publications Teaching in AHIMA Approved Education Programs Other HIM Instructions Other Contributions to Professional "Image" Not Classified Elsewhere Other Contributions Reason for Nomination Why have you chosen to nominate this member for the distinguished member award? Please provide a well written statement that is at least one paragraph and responds to the following questions:How has the member demonstrated strong leadership skills?How has the member shown integrity in their work?How has the member gone above and beyond to impact the HIM profession? * Signature * Clear Signature of * Date * If you are human, leave this field blank. SubmitΔ
