Component Group Application

Component Group Application
CHIA members looking to establish a Component Group (CG) are invited to submit an application. Component Groups are an exciting opportunity to foster engagement, collaboration, and professional growth within California’s health information community.

The following resources provide essential information on Component Groups to support you in this process. Get started today and take the next step in shaping CHIA’s engagement network.
- Sample Component Group Application
- CHIA Strategic Plan
- CHIA Component Group Guiding Principles
- CHIA Component Group Approval Rubric
- Component Group FAQs
Component Group Name

Provide the proposed name of the Component Group.

Example: Behavioral Health Settings Engagement Network
Component Group Name*
Purpose / Mission Statement

Describe the purpose of the Component Groups (which also could be the group’s proposed Mission Statement)

Example: To provide a forum for HI professionals who work in Behavioral Health Settings to collaborate on LEADing practices, discuss operational challenges and learn from others in the same environment.
Proposed CG Community Benefit(s)

Enhance communication and networking opportunities for members of the Component Group.Serve as a primary impetus to identify CHIA continuing education opportunities to promote professional development.Contribute to digital content designed to meet the needs of Californias health information professionals and provide information for publication, including papers, articles and leading practices.Foster a culture of volunteer collaboration and engagement while promoting leadership development opportunities.Assist with grassroots advocacyOther
Please select the strategic initiative from CHIA's Strategic Plan that best aligns with the proposed purpose of forming the Component Group.
Proposed Group Governance/Responsibilities

Describe your vision for how the group will function and be monitored to foster engagement. These may include how the co-facilitators may govern the Component Group, such as defining member composition, decisions, financial needs (if any), meeting scheduling, virtual connection events, and communication.

Example: The facilitator or co-facilitator will oversee group engagement and foster communication by encouraging posting at least once per month and messaging members monthly and quarterly virtual gatherings to encourage engagement.

Define the CG Structure & Engagement Metrics (describe the specifics for how the CG will operate and its success be evaluated)

	Metrics
Anticipated number of members who may participate (minimum size to begin a CG = 5)
Describe the method of online engagement, if needed to meet virtually outside of the CHIA digital platform (For example, Zoom, Teams)
The CHIA digital platform offers Topic “Forums” for discussion purposes. Describe how many forum topics will be created when the group is formed. (For example, Two Forums Topics will be provided)
Anticipated number of virtual gatherings. (For example, Zoom meetings bi-annually)
Other

How you plan to measure the effectiveness of engagement with group members.
(For example, One posting per co-facilitator & member per month; increase CG membership by 10%)

Other Examples of Success Measures
- One peer-reviewed blog article posted per quarter, one Board approved LEADing practice (tip sheet) provided for California’s HI community per year, etc.
- CG expects to increase the number of upgraded CHIA members by 5 within six months of launch
- At least one CEU topic submitted for consideration for CHIA’s Professional Education Committee
- X-number of interactions/activities within the group forums and/or feed to determine engagement.
For a Component Group to operate, a minimum of two co-facilitators are required and updated annually. Please provide their contact information in the fields below (minimum of 2 required)*
Office Technology Support. Describe any anticipated resource needs from the CHIA office staff such as technology requirements, training, document sharing, communication tools, etc. *
Are there anticipated needs for funding?*

NoYes
What are the anticipated needs and approximate amount? *
Application Submitted by*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Should be Empty: