CDH Application Application for the Certified Digital Health Program Step 1 of 5 20% Name(Required) First Last Organization Name(Required) Title(Required) Primary Email(Required) Secondary Email Primary Phone Number(Required)Text Phone Number (if different)LinkedIn Address Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Time Zone(Required) Select level of application(Required)Professional LevelLeader LevelExecutive Level Highest degree earned(Required)Associate DegreeBaccalaureate DegreeMaster's DegreeDoctorate DegreeN/AIssuing Institution(Required) Degree area of concentration(Required) Date Issued(Required) MM slash DD slash YYYY Upload Resume or CV(Required)Max. file size: 1 GB.Who do you report to?(Required)(i.e. CIO, VP, Marketing Director, Sales Manager, etc.) Start Date in current role(Required) MM slash DD slash YYYY End Date in current role(Required)Put today's date if current. MM slash DD slash YYYY Previous Healthcare Experience: Title Organization Name Who did you report to?(i.e. CIO, VP, Marketing Director, Sales Manager, etc.) Start Date of previous role MM slash DD slash YYYY End Date of previous role MM slash DD slash YYYY Add more experience? Yes No Previous Healthcare Experience: Title Organization Name Who did you report to?(i.e. CIO, VP, Marketing Director, Sales Manager, etc.) Start Date of previous role MM slash DD slash YYYY End Date of previous role MM slash DD slash YYYY What level best describes you?(Required) Student Entry-level healthcare worker Manager Team/Department Lead Consultant Director Executive President/C-Suite Area of concentration/experience:(Required)(select best option) Government Information Technology/Services Information Security Medical Military Pharmaceuticals Sales Other If other, please explain:(Required) Do you hold membership within CHIME?(Required)CHIME provider/payerCHIME FoundationAEHIAAEHISAEHITNoneWill you need testing accommodations?YesNoIf yes, please provide detail(Required) Enrollment related to:(select all that apply) Career Change Personal Interest Promotion Work Required Other If other, please explain: How did you hear about the CDH Program? CHIME Team Member Colleague Email Event Social Media Website Other If event, please provide event name. If other, please explain: I certify that the above information is accurate and true.(Required) I agree
