AHA Equity Transformation Partner

Program Application

The application process has two parts – information collection on the form below and submission of one of the following: case studies, publications, reports and articles. To begin the evaluation process, please complete the application in full.

The ETP review committee will be in contact if questions arise or additional information is needed to complete the vetting process. The committee will provide final determination of application acceptance.

Your Contact Information

First Name*

Last Name*

Title*

Email*

Phone

Organization Information

Organization Name*

Organization Website Address

Do you currently have existing contracts with any state hospital associations and/or hospitals and health systems?

Select or enter value

Application Preference and Focus Area

Which Program level are you applying for?*

Select

Levers

Please identify the Equity Roadmap Levers your services address.

Select the top two levers that apply. If all are applicable, select "All Levers."*

Select

Boutique and Corporate Firms

For Boutique & Corporate Firms you will have the opportunity to add additional team members names to the program. For this application, please provide consultant names tied to references provided (enter information below).

Boutique & Corporate Firms - please enter additional team members names

References

Each applicant must provide three references from recent clients.

Reference 1

Contact Information (Name, Title, Org)*

Brief description of work conducted for client.*

Email*

Phone

Reference 2

Contact Information (Name, Title, Org)*

Brief description of work conducted for client*

Email*

Phone

Reference 3

Contact Information (Name, Title, Org)*

Brief description of work conducted for client*

Email*

Phone

Case Studies/Org Profile and Mission

Applicants must submit one of the following: case studies, publications, reports and articles. As well as an organization profile and mission statement. Please upload all documents here.

File Upload*

Drag and drop files here or

If applicable, describe any additional DEIB (Diversity, Equity, Inclusion, Belonging) and/or health equity services your organization provides to the healthcare field.

I have reviewed the IFDHE Health Equity Roadmap and the Six Levers of Transformation. I agree that the services my organization provides and my organizational point of view are, and will be, in alignment with the Health Equity Roadmap as we support member hospitals.*

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How did you hear about this program?*

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