2023 Regional Leader Award Application

2023 Regional Leader Award Application

ASHE promotes the Regional Leader Award program as an opportunity to recognize future leaders or young professionals within the field of health care engineering and facilities management community.

This is the official application for the ASHE Regional Leader Award.

As the preparer of this application, you must complete this form in its entirety, including a signature and date. Before beginning this application, make sure you have 30-45 minutes of uninterrupted time to fully complete the application. You will not have the opportunity to save your answers and return later to complete the application. Please follow the directions as indicated and answer all applicable questions. After you have completed the application, you will be instructed to upload the supporting documentation and the candidate's professional photo.

The application deadline is April 1, 2023.

Please refer to the Regional Leader Award criteria for more information and examples. You can download a copy of the criteria at https://www.ashe.org/awards/regional_leader

If you have questions, contact Charmaine Osborne at cosborne@aha.org.

REGIONAL LEADER APPLICATION PROCESS

Please complete this application in its entirety. The application is divided into eights (8) parts: Part 1 - Candidate's application and contact information Part 2 - Membership Part 3 - Professional resume Part 4 - Letters of recommendation (2) Part 5 - Written narrative (written by the candidate) Part 6 - Preparer's contact information Part 7 - Signature and date Part 8 - Supporting documentation and photo

PART 1 - CANDIDATE'S APPLICATION

Provide the contact information of the individual being nominated for the Regional Leader Award.

Application

Indicate if the candidate has ever been nominated for this award in the past

Select or enter value

ASHE Region*

Indicate the Region the candidate will be representing

Select or enter value

Chapter*

Indicate the name of the ASHE Affiliate Chapter supporting this candidate. If a self-nomination, please indicate N/A

First Name*

Last Name*

Job title

Organization*

City*

State*

E-mail*

Phone Number*

Year of Birth*

Part 2 - MEMBERSHIP

Individuals nominated for Regional Leader must have two (2) years of continuous membership with ASHE National or with an ASHE Affiliate Chapter at the time of application. An official letter that verifies continuous membership (from ASHE or Chapter) must be included as part of the supporting documentation.

Membership Type*

ASHE Member

ASHE Affiliate Chapter

Membership*

Yes, I have an official letter to confirm membership

No, I do not have an official letter to confirm membership

Part 3 - PROFESSIONAL EXPERIENCE/RESUME

Candidate must be actively employed by or in a health care facility.

Professional resume*

A copy of the candidate's resume must be included as part of the supporting documentation.

Yes, I have included a copy of the candidate's resume

No, I have not included a copy of the candidate's resume

Years of experience*

Supporting documentation must include a copy of your resume to demonstrate years of experience. Please indicate years of experience.

Part 4 - LETTERS OF RECOMMENDATION

Candidate must have the support of their local chapter, peers, colleagues and/or immediate supervisor. The application must include two (2) letters of recommendation from any of the following individuals: --Immediate supervisor and/or CEO --Local Chapter President and/or Officer --Fellow ASHE member Recommendation letters must address the following: --Reason for the nomination --Leadership qualities --Contribution on projects, committees, etc.

Letter of recommendation #1*

Indicate name and title of the individual who submitted the letter of recommendation. EXAMPLE: James White, President of XYZ Hospital

Letter of recommendation #2*

Indicate name and title of the individual who submitted the letter of recommendation. EXAMPLE: Phillip Brown, Chapter President, HESNI, 2018

Part 5 - WRITTEN NARRATIVE

The application process requires that the candidate submit a narrative written in their own words. The candidate's written narrative must be included as part of the application.

The written narrative must be a minimum of 200 words

The written narrative must address any of the following:

a) Contribution to ASHE national

b) Contribution to state and/or local chapter

c) Contribution to the field and/or profession

d) Leadership qualities

e) Ability to work with others

f) Professional goals

g) Career achievements, awards, etc.

h) Community involvement

Written narrative*

The written narrative must be included as part of the supporting documentation.

Yes, I have obtained a copy of the candidate's written narrative

No, I have not obtained a copy of the candidate's written narrative

Part 6 - PREPARER'S CONTACT INFORMATION

Please provide your name and contact information where you can be reached with questions.

Preparer's full name*

Preparer's phone number*

Preparer's email address*

Part 7 - SIGNATURE & DATE

Please sign and date this application by indicating a check mark in the Signature box below.

Signature*

I hereby certify that all statements and responses I have made in this application, and all documentations enclosed herewith, are true, accurate and authentic to the best of my knowledge. Further, I acknowledge that I have reviewed this submission for completeness and accuracy and understand that an incomplete submission will be deemed ineligible for review by ASHE. Please check the box below to serve as your official signature.

Today's Date*

Comments

Feel free to include any brief comments or other relevant information specific to this application that you would like to have considered when reviewing this application.

PART 8 - SUPPORTING DOCUMENTATION

As the preparer of this application, you will be required to provide supporting documentation that will be reviewed by the task force. The supporting documentation validates the answers and/or statements that you have provided on this application. To ensure a thorough review of your application, be sure your supporting documentation is compiled and organized for easy reference and verification, as indicated below: --Application --Membership --Professional resume --Letters of recommendation (2) --Written narrative (min. 200 words) --Photo (JPG file)

Required information

Carefully read and follow the instructions below. You will upload two (2) separate files/documents. File 1 - Supporting documentation Make sure that you have compiled and scanned all required documentation as one (1) PDF file. Separate documents will not be accepted. File 2 - Professional photo (headshot) Must include a high-resolution color photo of candidate (JPG file). Photo must be sent at time of application.

INSTRUCTIONS TO UPLOAD SUPPORTING DOCUMENTATION*

To upload your documents click the "browse files" link below. Search and enter the document name from your computer hard drive or zip file. Click "OK/Enter". Repeat process to upload the second file. Maximum file limit (total of both files) should not exceed 30MB.

Drag and drop files here or

SUBMITTING YOUR APPLICATION

As the preparer of this application, you are responsible for the accuracy and completeness of this application.

Please review the following before submitting your application:

--Make sure you have completed the application in its entirety.

--Review your answers.

--Check to see you have properly uploaded your supporting documentation and photo.

--Make sure your application is signed and dated.

--Be sure to check the box marked "Send me a copy of my responses" and enter a valid e-mail address, so you can receive a copy of this application for your records.

--When you are ready click SUBMIT. You will get a notification of receipt via e-mail.

The candidates selected for the Regional Leader Award will be notified by June 16, 2023. Other candidates and the preparers will be notified by June 30, 2023.

If you have questions OR if there are any changes and/or additions to your application after it has been submitted, contact Charmaine Osborne at cosborne@aha.org for further instructions.

Send me a copy of my responses

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