Rising Star Award Nomination Form

2020 KHIMA Rising Star Award

Please read over our KHIMA Rising Star Award Guidelines before filling out an application.

Nominee Information

Name *

First

Last Name *

Last

Job Title *

AHIMA ID *

Phone Number *

Work Address *

City *

State *

ZIP Code *

Number of years in the HIM profession *

Nominator Information

Name *

First

Last Name *

Last

AHIMA ID *

Email Address *

Phone Number *

Address *

City *

State *

ZIP Code *

Education

Please list the nominee's education credentials. *

Leadership

Credentials *

Awards/Recognitions *

Leadership Roles *

Reason for Nomination

Please explain why you have selected this nominee. *

Signature

Nominator's Signature *

Date *

Application Deadline is June 1st, 2020.

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Rising Star Award Nomination Form

Nominee Information

Nominator Information

Education

Leadership

Reason for Nomination

Signature

Education

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