Candidate’s name:

 Job Title:

 Organization:

 Address:

 City:

 State:

 Zip:

 Phone:

 Fax:

 Email:

 Name of your
 organization’s CEO:

The following items must be included with your application form (you will be able to upload them on the next page):

• A written, detailed description of the organizational transformation,
• A description of the role that IT and the CIO played in that transformation,
• A description of the positive results that the change made in the organization and its delivery of quality healthcare, and
• A description of how this transformation change will be maintained and why/how it is replicable in other organizations.
• A statement/letter of recommendation from the organization’s CEO that validates the organizational change, the impact, and the role played by the CIO in the transformation.

All entries should include a 2 paragraph executive summary, and be limited to no more than 10 pages total.