PROGRAM CERTIFICATE COMPLETION FORM
HRM CERTIFICATE IN HEALTHCARE RISK MANAGEMENT PROGRAM
After attending all three modules, please supply the following information:
______
Name (Please print or type) Title
______
Institution or Organization
______
Major Area of Responsibility
______
Address City, State, Zip Code
(_____)______(_____)______
Telephone Number Fax Number e-Mail Address
PLEASE ENTER THE DATES AND LOCATIONS OF THE MODULES COMPLETED IN THIS SERIES.
(Attach a copy of all certificates of attendance.)
Essentials in Healthcare Risk Management
Date: ______Location: ______
(City & State)
Applications in Healthcare Risk Management
Date: ______Location: ______
(City & State)
Advanced Forum in Healthcare Risk Management
Date: ______Location: ______
(City & State)
Barton Certificate in Healthcare Risk Management
Program Certificate Completion Form
Please list and send supporting documentation for modules taken under the series prior to 2003 which you would like credited towards the Certificate of Completion:
Module I Health Care Risk and Insurance Management: Components of a Fundamental Program
Date: ______Location: ______
(City & State)
Module II Claims Management and Legal Issues for the Health Care Risk Manager
Date: ______Location: ______
(City & State)
Module III Clinical Risk Management
Date: ______Location: ______
(City & State)
Module IV Cents & Sense of Risk Management: Risk Financing, Workers’ Compensation, Safety & Security
Date: ______Location: ______
(City & State)
Module V Survival Skills for the Risk Manager in the Organization
Date: ______Location: ______
(City & State)
Years of experience as a health care risk manager? ______
Are you an ASHRM member? ______Since?______Chapter member? ______
RETURN THIS FORM TO: Grecelda Buchanan
Program Coordinator
American Society for Healthcare Risk Management
155 N. Wacker Drive, Ste 400
Chicago, Illinois 60606
Fax to: 312/278-0505
Email to: