Kansas Association of Risk and Quality Management

* First

* Last

Title of Position

* Hospital/Firm name or indicate Retired

Business Address

City

State

Zip

* Business Phone

Fax

* Email Address

Nursing License Number (For any upcoming available CEUs)

Areas of expertise you would be willing to make available to other KARQM members:

* What areas are you responsible for?

Do you have any certifications?

CPHQ
CPHRM
CPPS

* What District would you be serving? (check one)

* Are you a member of ASHRM? (The American Society for Health Care Risk Management)

Yes
No

Are you interesting in being mentored?

New manager and would like a mentor
Would like a different mentor
Please keep me with my current mentor
Remove me as a mentee
No

Are you willing to be a mentor?

New mentor
Already mentor but have capacity to help more
Already a mentor but don't assign any more to me
Remove me as mentor
No

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