Member Information

Membership Application

Name:

Home Address:

City, State, Zip:

Home Phone:

Place of Employment:

Address:

City, State, Zip

County:

Work Phone

Fax

Department

Type of Organization:
Hospital Managed Care Rehab Psych Home Health Consultant ECF
Other (Specify):

Primary area of responsibility:
UM/Case Management Risk/Safety PI/QI/CQI
Other (Specify):

Are you a member of NAHQ?: Yes No
If yes, please choose one of the following: Individual member or Institutional Member
Are you a CPHQ?: Yes No
Year of initial certification:
If a new member, how did you hear about our organization?:

Primary email address:
Secondary email address:

DUES ARE $40.00 PER YEAR. Make check payable to InAHQ. Your home address will not be published
Send dues and questions to:
Amy Miles
St. Mary's Medical Center
3700 Washington Ave.
Evansville, IN 47750
Phone: 812-485-7887
Fax: 812-485-7862
ALMiles@stmarys.org

Member Ladder

Achievement Points Calculation Sheet
Directions:
Membership Ladder Application

Achievement Points Calculation Sheet
Directions: Circle the highest points of achievement for each category and write the number of points achieved in the blank lines provided for each category. Please note the time frame for each category. Please complete the form and return on/or before January 31st.

If you have any questions please contact Carol Blackwell (cblackwell10@msn.com) at 317-287-2718 . Pins will be awarded at InAHQ's Annual Education Conference in the Spring, based on accomplishments as follows:

Join INAHQ-Membership Pin
15 points -receive a synthetic sapphire guard
Additional 12 points-recieve a synthetic ruby guard
Additional 12 points-recieve a synthetic emerald guard
Additional 12 points-recieve a synthetic diamond guard

(Additional points may be earned years after the initial award and the subsequent guards awarded).

Please provide the following:

First Name Last Name
Day Phone Number

Email:

CATEGORY I: Total Job Experience in Healthcare Quality
1 Point - 1 year or less
2 Points - >1-3 years
3 Points - >3-6 years
4 Points - >6-10 years
5 Points- >10 years
Point(s) Earned

CATEGORY II: Total Years of InAHQ Membership
1 Point - 1 year or less
2 Points - >1-3 years
3 Points - >3-6 years
4 Points - >6-10 years
5 Points- >10 years
Point(s) Earned

CATEGORY III: InAHQ Regional Meeting
Attendance/Participation
2 Points - attended 2 or more regional meetings in a calendar year.
1 Bonus Point - in addition to one of the above, attended InAHQ's annual education conference
Point(s) Earned

CATEGORY IV: Support of InAHQ
Count all points for this area for each unique item.
1 Point - hosted a regional meeting
2 Points - served on a team
3 Points - served as a team leader
4 Points - served as regional representative or an elected officer other than President
5 Points - served as President of InAHQ
1 Bonus Point - to be added if served as delegate or alternate to InAHQ's House of Delegates
Point(s) Earned

CATEGORY V: Certification (CPHQ)
5 Points - obtained CPHQ certification

5 Points - obtained CPHQ recertification
Point(s) Earned

CATEGORY VI: Poster Creation in Healthcare Quality
Count all points for this area for each unique item.
1 Point -presented at your workplace
2 Points -presented to an external organization and/or InAHQ (at regional level)
3 Points -presented to any state or national association/organization
4 Points -presented to InAHQ(at state level)
5 Points -presented to NAHQ
Point(s) Earned

CATEGORY VII: Speaker/Co-speaker Presentation in Healthcare Quality
Count all points for this area for each unique item.
1 Point -presented at your workplace
2 Points -presented to an external organization and/or InAHQ (at regional level)
3 Points -presented to any state or national association/organization
4 Points -presented to InAHQ(at state level)
5 Points -presented to NAHQ
Point(s) Earned

CATEGORY VIII: Publication in Healthcare Quality
2 Points - published for an external organization
3 Points - published for any state or national association/organazation
4 Points - published for InAHQ
5 Points - published for NAHQ
Point(s) Earned

Total

Member Award

Nominee Information

Complete the form at the bottom of the page to nominate a candidate.

Mechanism

A. Nominations may be made by member(s) by obtaining and submitting a signed nomination form to the Marketing Team prior to December 1st.

B. The Board of Directors will select the award winer at the March Board meeting. The Board reserves the right to accept or reject the nomination of any candidate based upon the information provided.

C.Formal presentation of the award will take place at the annual education conference. The award will be published in the InAHQ-Tips edition following the conference.

Policies Regarding Nominees and Recipients

A.Elected members of the InAHQ Board are ineligible for awards during terms of office.

B.Honorary members are eligible.

C.There may be no recipient of the award in a given year if the Board determines nominees have not met the eligibility criteria.

D.Recipients may receive only one Distinguished Member Award

Eligibility Criteria

Candidate must be a current member of InAHQ and have made an outstanding contribution to the profession in any of the following:

A.InAHQ participaion as a Board member, team leader, team member and/or delegate to the Inahq house of Delegates.

B.National participaion in NAHQ as a Board member, team leader, team member and/or Leadership Council(formerly House of Delegates) member.

C.Dissemination of knowledge of practice through practice through voluntary consultation to others in the field. Recognized resource person inarea of specialty.

D.Successful completion of CPHQ certification and recertification.

E.Publication of healthcare quality management articles in InAHQ publication or other professional healthcare journals.

F.Present/instructor at region, state, or national workshops, seminars, conferences or in service training program.

	First Name:
Last Name:
Title:
Organization :
Address:
City and State:
Zip:
Day Phone:
FAX:
Email Address:
Is the Nominee a InAHQ Member?	Yes Yes No
If yes, Number of years:
Person Nominating the Candidate:
Which Criteria does this individual meet?	A B C D E F
Why Does This Candidate Deserve This Award?

By clicking the "Submit" button you are agreeing that all of the information you have provided about the nominee for the InAHQ Distinguished Members Award is accurate.
Please click submit to send in your nomination