CALIFORNIA HEALTH eQUALITY ADVISORY COMMITTEE

NOMINATION FORM

This form must be completed in its entirety. Please do not PDF this form prior to submitting it electronically. Please leave it as a Word file.This form, the required 200-word biosketch, and the optional material (see Call for Nominations) should be submitted via e-mail to iphi@ucdmc.ucdavis.edu, with the subject line “CHeQ HIE Advisory Committee” or a hardcopy sent with guaranteed delivery to IPHI, 4800 2nd Avenue, Suite 2600, Sacramento, CA 95817.All nominations MUST be submitted by Friday, October 26, 2012, at 5:00 pm Pacific Time.

Information about the person being nominated:First NameLast NameSuffix (MD, PhD, etc.)TitleOrganizationMailing Address 1Mailing Address 2CityState Zip CodeTelephoneEmail

If this is NOT a self-nomination, submit the following additional information about yourself: First NameLast NameSuffix (MD, PhD, etc.)TitleOrganizationTelephone EmailI have contacted this individual and he/she is willing to serve if selected

INSTITUTE FOR POPULATION HEALTH IMPROVEMENTUC DAVIS HEALTH SYSTEM4800 SECOND AVENUE, SUITE 2600SACRAMENTO, CALIFORNIA 95817TELEPHONE: (916) 734-4754