1 2 3 Full Name* First Last Designation(i.e. PhD, CHCIO, FCHIME)Email* Organization Name*Job description*(or a brief statement that highlights your current job responsibilities)Current organizational chart of your IT department that shows your position and those who report to youIT Department Organizational Chart*If you have one organizational chart that shows both the IT department and your direct reports, and to whom you report, you only need to submit the document once.Current organizational chart showing where you fit into the organization as a whole and to whom you report.Whole Organizational ChartIf you have one organizational chart that shows both the IT department and your direct reports, and to whom you report, you only need to submit the document once. Individual DemographicsProfile PhotoAccepted file types: jpg, png.Job Title*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Work PhoneCell PhoneFor internal purposes only.Assistant Name First Last Assistant Email Birth Date Gender* Male Female Prefer not to disclose EthnicitySelect oneAfrican AmericanAsianCaucasianEast IndianHispanic/LatinoMiddle EasternNative AmericanOtherPlease Specify(optional)What area(s) are you accountable/responsible for: Biomedical/Clinical Engineering Informatics (clinical, nursing) Medical Records/HIM Telecommunications Information Security Privacy Data Analytics/Business Intelligence Select all that applyTitle of the person that you report to:Do you actively participate in your organizations strategic planning activities? Yes No Do you chair the organizations IT steering/governance committee? Yes No Other Association Memberships:Professional Certifications:Healthcare IT Start Date: Organization DemographicsDoes your Organization participate in an Integrated Delivery System/Network? Yes No Network/System Name:Organization Type:Select oneAmbulatory Facility/ClinicBehavioral Health CareGroup Practice/ ClinicHealth Insurer/ Insurance OrganizationHIEHome HealthHospiceHospital/Acute Care FacilityLab ServicesLong Term Care/ Nursing Home/ SNFManaged CareMSORehabilitationSurgical CenterOtherPlease SpecifyHospital TypeSelect OneAcademic Medical CenterChildren's HospitalCommunity HospitalCritical AccessResearch HospitalCancerCardiacOtherOrganization Ownership Non-Government Not-For-Profit Non-Government For Profit Government- Military Government- City, County, State Is your Organization part of an ACO? Yes No Name of ACONumber of Organization EmployeesNumber of total IT staff in FTE'sNumber of Outsourced IT staffNumber of Staffed Inpatient BedsSelect One1-2526-99100-249250-399400-1,0001,001 +Not ApplicablePrimary EHR VendorOther significant Vendors UsedPrivacy Policy* Check here to indicate that you have read and agree to the CHIME privacy policy terms. Our Commitment To Privacy: Your privacy is important to us. To better protect your privacy we provide this notice explaining our online information practices and the choices you can make about the way your information is collected and used. The Information We Collect: This notice applies to all information collected or submitted on the College of Healthcare Information Management Executives (CHIME) website. The types of personal information collected on these pages are (but not limited to): - Name - Title - Employer - Address - Email address - Phone number - (Etc.) On some pages, you can submit information about your organization. Types of organizational information collected are ( but not limited to): - Structure - Type - Teaching Status - Business Lin - (Etc.) The Way We Use Information: We use the information you provide about yourself and/or your organization only to 1) better identify and connect you with members (and them with you) whose organizations, demographics, and interests are similar in nature, and 2) better understand your professional needs and interests so that we may provide better customized services tailored to your individual preferences. We may use non-identifying and aggregate information to better design our website. Finally, we never use or share the personally identifiable information provided to us online in ways unrelated to the ones described above without also providing you an opportunity to opt-out or otherwise prohibit such unrelated uses. As a practice, we do not share the information you provide with any outside parties. Our Commitment To Data Security: To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information, we have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information we collect online. How You Can Access Or Correct Your Information: Currently, you can access all your personally identifiable information that we collect online and maintain by calling our Membership Services department at 734.665.0000. We use this procedure to better safeguard your information. You can correct factual errors in your personally identifiable information by sending us a request that credibly shows error. To protect your privacy and security, we will also take reasonable steps to verify your identity before granting access or making corrections. How To Contact Us: Should you have other questions or concerns about these privacy policies, please call us at 734.665.0000 or send us an email to [email protected]EmailThis field is for validation purposes and should be left unchanged.
