AMIA Working Group Nominations 2024 | AMIA - American Medical Informatics Association

Self Nomination

First Name

Last Name

Email Address

Title

Organization

Education

Please note highest degree earned

Short bio

How long have you been an AMIA member?

Less than 5 years

5-10 years

10-20 years

More than 20 years

AMIA Engagement and Participation

(participation in AMIA committees, working groups, etc)

Demographic Information

Date of birth

Gender

Race (check the race with which you identify)

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

Native American or Alaskan American

Two or more races (select those that apply)

Prefer not to answer

Optional: Additional specifying data for ethnicity/race/nationality e.g. Middle East North African (MENA); Indian subcontinent

Ethnicity

Hispanic or Latinx (may be of any race)

Prefer not to answer

Experience

Leadership Skills

Please describe your leadership skills.

Working Group leaders are expected to think strategically and analytically and be able to effectively communicate their thoughts and the reasons for them. A demonstrated understanding of the differences between oversight and supervision is also desired.

Perspective Add

What new perspective/s will you bring to the AMIA Working Groups?

To support diversity and inclusion in our organization we are looking for perspectives or lived experiences not reflected on the current AMIA Working Groups. We hope to bring new or important perspectives that are underrepresented (demographic diversity/institutional/corporate/focus area diversity).

Committed AMIA Member

Personal Statement

Headshot

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Terms

Terms and Conditional Agreement

I agree with the terms and conditions.

COI Agreement

I have completed my COI form (If you haven't completed the COI form, please complete the COI online form.

Date

Signature

Before you submit, please review your information carefully.

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