KHIMA Rising Star Award

Nominee Information

Name *

Name

Name

Name

Email *

Phone Number *

Address *

Address

Address

Address

Address

Address StateAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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 StateAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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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