Camss Prospective Leadership Form

CAMSS PROSPECTIVE LEADERSHIP FORM

The Colorado Association of Medical Staff Services (CAMSS) is a thriving, growing, professional organization, with an ongoing need for talented, energetic leadership. Are you organized, enthusiastic, and ready to take on new challenges? Are you willing to work hard and make a commitment to your peers, as well as to your own professional growth? Being elected for a CAMSS leadership position can provide opportunities to "shine" in ways that your daily job may seldom offer. Whether you have minutes or hours of potential "volunteer" time available each month, consider expanding your horizons by working with your State Association. Take a moment to print and complete this form, then forward it to Anmarie Masters, Chair of the Nominating Committee, via email: no later than June 1, 2017.

CANDIDATE: Please submit a current photo, resume, and brief biographical sketch to be used in election process, with this Leadership Form.

NAME
ORGANIZATION
ORGANIZATION ADDRESS
TELEPHONE / ( ) / FAX / ( )
EMAIL ADDRESS
CERTIFICATIONS / YEAR / EDUCATION / MAJOR
  CPMSM / MA/MS
  CPCS / BA/BS
  CPHQ / Associate
  OTHER: / High School
RESPONSIBILITIES: Check those areas for which you have CURRENT direct responsibility.
  Credentialing /   Graduate Medical Education
  Privileging /   Continuing Medical Education
  Medical Staff Organizational/Leadership /   Utilization Review
  Physician Services/Relations /   Database Management
  Healthcare Law /   Consulting
  Risk Management /   Recruitment
  Performance Improvement /   Physician Orientation
  Social Activities /   Other:
RESPONSIBILITIES: Check those areas for which you have direct responsibility during the past ten years.
  Credentialing /   Graduate Medical Education
  Privileging /   Continuing Medical Education
  Medical Staff Organizational/Leadership /   Utilization Review
  Physician Services/Relations /   Database Management
  Healthcare Law /   Consulting
  Risk Management /   Recruitment
  Performance Improvement /   Physician Orientation
# of healthcare practitioners you are responsible for: ______
# of years in healthcare: ______
Leadership Interests - Indicate those positions and areas of leadership you would be most interested in being considered for, along with a brief explanation.
President President-Elect Secretary Treasurer Website Membership Coordinator Outreach Bylaws
Career/Work Experience - List past ten years only, beginning with most recent.
Include title, organization and dates (or attached resume).
CAMSS/NAMSS Activities - Please indicate past and current CAMSS and NAMSS
activities and board positions held in the past ten years:
Special Honors / Awards - Indicate any special honors or awards that you have received during the past ten years.
Goals - Please submit your personal statement on goals you wish to achieve while serving on the CAMSS board.
References - Please submit the names and contact information for two (2) peer references, (cannot be a current CAMSS Board member), and one that is workplace-related. References will be asked to address qualifications such as leadership, organizational and communications skills, as well as current competence in the field.
Name:______
Organization: ______
Address:______
______
Telephone: ______
Email Address:______ / Name:______
Organization: ______
Address:______
______
Telephone: ______
Email Address:______

Are you currently a CAMSS member? Yes No

Last CAMSS Conference Attended ______

Signature: ______Date:______

Return to no later than Thursday, June 1, 2017.