INSTITUTE FOR POPULATION HEALTH IMPROVEMENT
UC DAVIS HEALTH SYSTEM
4800 SECOND AVENUE, SUITE 2600
SACRAMENTO, CALIFORNIA 95817
TELEPHONE: (916) 734-4754
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 Name
Last Name
Suffix (MD, PhD, etc.)
Title
Organization
Mailing Address 1
Mailing Address 2
City
State
Zip Code
Telephone
Email
If this is NOT a self-nomination, submit the following additional information about yourself:
First Name
Last Name
Suffix (MD, PhD, etc.)
Title
Organization
Telephone
Email
I have contacted this individual and he/she is willing to serve if
selected