Region 5 Program Improvement Advisory Committee

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

County*

Email*

Phone*

Perspectives and Experience*

We are required by the state to have a variety of perspectives and experiences represented on this committee. Please check all that apply to you:

Present Employer/Occupation*

Why do you want to participate on the Regional PIAC?*

What health care issues are important to you and why?*

What skills, experience, and perspective do you feel you can share?*

If you are a member, family member and/or caregiver, how do you feel you represent the diversity of the Health First Colorado membership? (If this doesn't apply to you, please write "not applicable")*

How did you hear about this region's Program Improvement Advisory Committee (PIAC)?*

Demographic Information

A response to the following is optional, but is encouraged. The information will be taken into consideration when we select committee members in a good faith attempt to have equal representation from all demographic areas.

Gender

Ethnicity

Certification*

I certify that the facts contained in this application are true and correct to the best of my knowledge. I further understand that the Colorado Open Records Act may require that certain information contained in this application be available for inspection by the general public. Certify by checking the box below:

Yes

Region 5 Program Improvement Advisory Committee

City & County of Denver

Region 5 PIAC