SOCIETY FOR HEALTH SYSTEMS ADVANCEMENT APPLICATION
Effective January 2006 | Revised April 22, 2015
To submit the nomination via e-mail, please complete the form with the criteria data and e-mail it as an
attachment to ppatterson@iienet.org. Attach any other supporting documentation for the nomination to
the e-mail.
If you can’t submit the nomination via e-mail, please complete the form, submitted with the criteria data for
consideration. Mail to:
SHS Diplomate
c/o Pam Patterson
3577 Parkway Lane, Suite 200
Norcross, GA 30092
Candidate Information:
SHS / IIE Member #: _______________________________________________
(Forgot your member number? Let us email it to you.)
Name: ___________________________________________________________
Job Title: _________________________________________________________
Organization: _____________________________________________________
Address: _________________________________________________________
City, State, Zip: ____________________________________________________
Work Phone: _____________________________________________________
Home Phone (optional): _____________________________________________
Fax Number: ______________________________________________________
E-mail Address: ___________________________________________________
Criteria 1 – Years of Membership
# of
years
Point
value
SHS Membership (Five consecutive yrs required.
This requirement may also be met with four
years as a professional member and two years of
student membership.)
x2
Years of student membership
X1
IIE Membership (while not an SHS member)
Total
x1
Total for Criteria 1
Required minimum credit is 10 points
Maximum credit is 20 points
Criteria 2 – Education
Proof of education level required. Credit given for highest level only limited to
one degree.
Point
value
Associates Degree
x5
Bachelors Degree
x 10
Masters Degree
x 15
Doctorate
x 20
Total
Total for Criteria 2
Required minimum credit is 5 points
Maximum credit is 20 points
Criteria 3 – Experience & Job Responsibility
Include positions held for one year or more. To add more lines, right click and “Add Row.” Multiply point value by the
number of full years in each position. You may provide a CV or resume in place of listing each position here. Please provide
point total on this form.
Organization / Location
/ Title / Dates
Responsibilities
# of
years
Point
value
Non-supervisory
positions, instructor
x1
Managerial or
supervisory, faculty
member
x2
Director and above,
including owner of
consulting practice or
faculty program
director
x3
Total
Total for
Criteria 3
Required minimum credit is 7 points
Maximum credit is 30 points
Criteria 4 – Publications / Presentations
Multiple presentations of same topic only count one time. You may provide a CV or resume in place of listing each
publication/presentation here. Please provide point total on this form. To add more lines, right click and “Add Row.”
Maximum credit is 30 points
Title of article /
presentation
Date
Title of
publication /
venue of
presentation
Point
value
Article on healthcare-related
topic in non-SHS / IIE
publication
x1
Article on healthcare-related
topic in SHS / IIE publication
x2
Presentation on healthcarerelated topic to a non-SHS /
IIE group
x1
Paper for SHS / IIE
Conference
x2
20 minute Presentation at
SHS / IIE conference
x1
50 minute Presentation at
SHS / IIE conference
x2
100 minute Presentation at
SHS/ IIE Conference
x3
Annual Pre-conference
workshop (4 hours)
x3
Keynote Presentation at
SHS/IIE Conference
x 10
Healthcare journal editorial
board member
x3
Healthcare journal editor
x7
Chapter in a book
X5
Book or monograph
published
x 15
Total
Total
for
Criteria
4
Required minimum credit is 4 points
Maximum credit is 30 points
Criteria 5 – Professional Participation
Position
# of
years in
position
Point
value
Total
SHS / IIE Participation
Committee or task force
member
x1
Committee or task force
chair, Conference Track
Chair, Conference Day Chair
x3
SHS Conference Chair
x5
Board of Directors
x 10
IIE chapter participation
Committee or task force
member
x1
Committee or task force chair
x2
Board of Directors
x5
Student Chapter Advisor
x2
Other professional local
or national society
participation
Chapter officer
x1
National committee member
x1
National committee chair
x2
National officer or BOD
member
x3
Total
for
Criteria
5
Required minimum credit is 5 points
Maximum credit is 50 points
Criteria 6 – Professional Development
Multiply point value by the number of events
Topics
Dates
Point value
Total
Webcasts or audio conferences
x1
x1
Conference
Dates
Point value
Total
Attendance at other professional
conferences
x2
x2
Conference
Dates
Point value
Total
Attendance at SHS / IIE conferences
(limit of 1 as a student attendee, all
applicants must have a minimum of one
SHS Conference attendance)
x4
x4
Total for Criteria 6
Required minimum credit is 10 points including one SHS Conference
Maximum credit is 25 points
Criteria 7 – Certification
Proof of certification or PE license must be submitted (PDF is acceptable).
Name of certification
Point
value
Other technical certification (Six Sigma Green Belt,
Microsoft, etc)
x5
Other professional certification (Six Sigma Black Belt,
CPHIMSS, ACHE, etc)
x 10
Professional Engineer
Total
x 20
Total for
Criteria 7
Required minimum credit is 0 points
Maximum credit is 20 points
Criteria 8 – Awards / Honors
Name of award
Presented by
Date
received
Point
value
Civic awards
x1
Other professional society awards
or honors
x1
IIE Senior member
x3
SHS / IIE award or honor
X5
IIE Fellow
x 10
Total
Total for
Criteria 8
Required minimum credit is 0 points
Maximum credit is 10 points
Totals
In order to qualify for Diplomate status, a minimum number of points must be earned in each of the first 6 criteria as
outlined below, but cannot exceed the maximum.
A minimum of 100 points must be earned to qualify for Diplomate status.
Total # of
points
received
Min #
of
Points
Max #
of
points
Criteria 1 – Years of Membership
10
20
Criteria 2 – Education
5
20
Criteria 3 – Experience & Job Responsibility
7
30
Criteria 4 – Publications / Presentations
4
30
Criteria 5 – Professional Participation
5
50
Criteria 6 – Professional Development
10
25
Criteria 7 – Certification
0
20
Criteria 8 – Awards / Honors
0
10
Total