DFASHRM Application -

DFASHRM Application -

Please complete the entire application process. Include all supporting documentation. ASHRM staff

may request additional documentation at a later date. Required documentation includes the

following:

• Documents that demonstrate compliance with continuing education requirements

(transcripts, certificates, etc.)

• Employment experience summary and current job description signed by the person you

report to. Indicate number of years of experience in position(s) with primary responsibilities

related to risk management.

• Documentation of contributions to the field (CV, resume, etc.)

• Two letters of reference.

Name

Date joined ASHRM

Title

Organization

Phone

Address

City

State

Zip

File Upload*

Please upload your resume , two letters of reference and any continuing education documents.

Drag and drop files here or

Submission as:*

Please check the correct box below:

First-time application

Reference Name*

Reference Title*

Reference Organization

Email*

Reference Phone

Reference Address

Reference City

Reference State

Reference Zip

Reference #2 Name*

Reference #2 Title*

Reference #2 Organization

Reference #2 Email*

Reference #2 Phone

Reference #2 Address

Reference #2 City

Reference #2 State

Reference #2 Zip

Academic/Professional Designations*

Please list academic/professional designations obtained, in addition to the CPHRM:

Select or enter value

Number of Continuing education hours*

List total number of education hours in the box below (At least 150 contact hours). Documentation must be provided for all

education hours with the correct content category.

Contributions to the Field of Risk Management

Applicants must meet all requirements in all three of the contribution categories listed below: Leadership, Publishing and Lecturing.

Leadership*

Applicant must provide at least two examples of health care risk management-related leadership positions

totaling at least four years of service, that are not a matter of routine job responsibilities, not held

concurrently and are each at least one year in duration.

Written verification is required of title and leadership position held provided by the organization cited

Publishing*

To meet the publishing requirement, you must submit two scholarly articles which clearly relate to patient

safety and/or risk management; and are peer reviewed with cited resources (e.g., through citations, a

bibliography, list of references, etc.) and published within five years prior to the date the application is

submitted

Lecturing*

Applicant must provide at least two examples of participation as a speaker or faculty member in risk

management programs, conducted within five years prior to the date the applicant is applying for recognition

(cite Content Category Code listed above in Continuing Education Criteria section). At least one

presentation must be at national or state level and at least one must offer continuing education credits.

Press Release*

Upon your award of a certification of recognition, ASHRM staff will send press releases to your hospital or

organization announcing your achievement. Please list names and addresses of your CEO/Administrator

and public relations officer.

Application Fees-This is just for reference.

Distinguished Fellow (DFASHRM)

$125

Reapplication After One Year

$50*

*Applicants who reapply for either designation within 12 months of the decision are exempt from

the application fee.

Invoice will be sent upon receipt of submission.

Signature*

I hereby certify that all statements and responses I have made in this application, and all documents

enclosed herewith, are true, accurate and authentic to the best of my knowledge.

Professional Recognition Checklist

Click here to review checklist before submission.

Form Date Field*

Send me a copy of my responses

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