HL7 Fundamentals Course Nomination Form
Please fill out this form completely to apply as participant for the HL7 Fundamentals Course.

There are only 20 scholarships available and a maximum of 4 participants per country will be sponsored. Priority will be given to government officers or those with experience implementing electronic health records in his/her country in the last five years.

Qualification to the program is on a first-come first-serve basis. As AeHIN Member, you can also nominate one other representative from your country. Since this scholarship is sponsored by our network, any new nominee will qualify only upon applying as member of AeHIN.
Sign in to Google to save your progress. Learn more
Full Name
Please provide name in this format: first name, middle name, and surname.
Country *
Nominated by *
Please fill this out if you are nominating someone from your country. If you are applying individually, write NONE in this field.
Designation/Position
Information in this field will be validated in the CV/resume you submitted upon applying as member. If you haven't accomplished your CV/resume, please email this in word format to secretariat@aehin.org. Participants who attended the 2012 AeHIN Workshop in Bangkok are automatic members of the network and may need not to submit their CV/resume.
Office Address and Contact Information
Provide a valid mailing address and phone number of the office. If using a local number, please indicate.
Email Address
Please indicate your email address which you opt to choose in throughout the HL7 Course.
How is this course relevant to your work?
In 100-200 words, please describe relevance of this course to your work on national HIS strengthening
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms