KHIMA Rising Star Award

Nominee Information

Name *

Name

Name

Name

Email *

Phone Number *

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 Information

Name *

Name

Name

Name

AHIMA ID *

Email Address *

Phone Number *

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

Contributions to the HIM profession *

Awards/Recognitions *

Leadership Roles *

Reason for Nomination

Why have you chosen to nominate this member for the Rising Star award? Please provide a well written statement that is at least one paragraph and responds to the following questions:

• How has the member emerged in their job position since graduation?
• How has the member demonstrated leadership characteristics in the HIM profession?
• What impact has the member had on the HIM profession, including the affiliated associations?

*

Signature

Signature *

Clear

Signature of *

Date *

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