CHIA Recognition Awards Nomination Form

Nominator's Details (if applicable)
Are you submitting this nomination on behalf of the CHIA Candidates Committee?*

Yes, I am a CHIA Candidates Committee volunteer or was requested to submit a nomination by a committee volunteerNo, I am submitting a nomination independently
Are you submitting this nomination on behalf of the Nominee?*

Yes, I am submitting this on the Nominee's behalfNo, I am self-nominating
Nominator's Name*

First NameLast Name
Nominator's Email (Primary)*
Nominator's Phone (Primary)*
Has the nominee been notified of this award nomination? *

Yes (Nominee will receive confirmation email and copy of nomination upon submission)No (Nominee will NOT be included in confirmation email)

Category Selection
Indicate the award category for which the nomination is being submitted?*

Distinguished Member AwardEducator AwardHIM Industry Champion AwardMentor AwardRising Star AwardVolunteer Award

Document Uploads
REQUIRED: Resume/Curriculum Vitae (PDF only)

Upload Resume/CV
Resume/CV may be attached to the original online nomination, or submitted separately to Nominations@CaliforniaHIA.org. Cancelof
Headshot Photo

Upload Headshot
CHIA includes photos in award announcements. Please upload a hi-resolution, color photo in JPEG, TIFF or EPS format. Cancelof
Other written material is suggested, but only if it supports the specific award/accomplishment (e.g. articles, project descriptions). (PDF only)

Upload Additional Material

Cancelof

Reference Support
REQUIRED: Identify 3-4 references for the nominee. A survey will be emailed to the reference gathering support based on award eligibility criteria. Please:
- Confirm the individual's willingness to be a reference.
- Collect their preferred email and phone number.
- Inform them a survey link will be sent
Reference #1 Name*

First NameLast Name
Reference #1 Email*
example@example.com
Reference #2 Name

First NameLast Name
Reference #2 Email
example@example.com
Reference #3 Name

First NameLast Name
Reference #3 Email
example@example.com
Reference #4 Name

First NameLast Name
Reference #4 Email
example@example.com
Should be Empty: