2023 Grace Award Application

SECTION I: DEMOGRAPHIC INFORMATION

Applicant demographic information.

Question Title

* 1. Demographic information of person completing application.

First and Last Name

Title

Organization

Location (City and State)

Question Title

* 2. Type of organization (select all that apply).

Rehabilitation

Ambulatory (free standing, surgery, or clinic)

Physician Office

Post-Acute Care Setting

Hospital

Rural Hospital

Critical Access Hospital

Multi-hospital Setting

Long Term Care

Home health

Payer/Insurance

Other (please specify E.g. QIO, ACO, HIE)

Question Title

* 3. Size of Organization

Beds

Licensed Beds (Rehab Center or Hospital)

Annual Visits (Surgery Center or Clinic)

Annual Inpatient Discharges (Hospital)

Annual Outpatient Visits (Hospital)

(For non-traditional settings) Number of patient lives served

Question Title

* 4. Organizational Staffing - Employees

1-250

251-500

501-1,000

1,001-5,000

5,001-10,000

10,000+

Question Title

* 5. Organizational Staffing - HIM Professionals

1-5

6-10

11-25

26-50

51-100

100+

Question Title

* 6. Organizational Staffing - AHIMA Credentialed HIM Professionals

1-5

6-10

11-25

26-50

51-100

100+

2023 Grace Award Application

SECTION I: DEMOGRAPHIC INFORMATION

Question Title

* 1. Demographic information of person completing application.

Question Title

* 2. Type of organization (select all that apply).

Question Title

* 3. Size of Organization

Question Title

* 4. Organizational Staffing - Employees

Question Title

* 5. Organizational Staffing - HIM Professionals

Question Title

* 6. Organizational Staffing - AHIMA Credentialed HIM Professionals

Question Title

* 7. Please list all job titles and credentials for the HIM professionals who are employed within your organization.