LRC Staffing Nomination Form

LRC Staffing Nomination Form

Please identify a minimum of two people (preferably three) to support the various activities of the LRC. For more information about the specific roles and responsibilities of the Information Coordinator, Evidence-based Practice (EBP) Specialist, and Technical Specialist, please see LRC Staffing: Roles, Responsibilities and Qualifications form.

Please submit this form to Mark Storey, Irina Carnevale, and your AIHA Regional ICT Coordinator as soon as possible. If LRC staffing assignments change throughout the duration of the LRC project, please complete and submit this form every time to reflect staffing changes.

Information Coordinator

Name:

Title:

Educational Background:

Phone number:

E-mail address:

English Ability (on a scale of 1-4, where 1 = not fluent at all and 4 = fluent):

Comments on ability to manage all listed responsibilities:

Comments on listed skills/qualifications that this person does not have:

LRC EBP Specialist

Name:

Title:

Educational Background:

Phone number:

E-mail address:

English Ability (on a scale of 1-4, where 1 = not fluent at all and 4 = fluent):

Comments on ability to manage all listed responsibilities:

Comments on listed skills/qualifications that this person does not have:

LRC Technology Specialist

Name:

Title:

Educational Background:

Phone number:

E-mail address:

English Ability (on a scale of 1-4, where 1 = not fluent at all and 4 = fluent):

Comments on ability to manage all listed responsibilities:

Comments on listed skills/qualifications that this person does not have:

Additional LRC Backup/Support

Which LRC Position(s) will this person be backing up or supporting:

Name:

Title:

Educational Background:

Phone number:

E-mail address:

English Ability (on a scale of 1-4, where 1 = not fluent at all and 4 = fluent):

Comments on ability to manage all listed responsibilities:

Comments on listed skills/qualifications that this person does not have:

Learning Resource Center (LRC) Project

American International Health Alliance (AIHA)