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• Full name✱
• Pronouns
  He/him
  She/her
  They/them
  Xe/xem
  Ze/hir
  Ey/em
  Hir/hir
  Fae/faer
  Hu/hu

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  • Use name only

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  • Custom

  Let the employer know what pronouns you use so that they can address you correctly.

• Email✱
• Phone
• Current location
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• Current company

Links

• LinkedIn URL
• Portfolio URL
• Other website

Source Information

• How did you hear about us?✱

Healthcare Background

• Do you have experience working in the healthcare industry?✱

  • Yes
  • No
• If so, do you have working knowledge of health information exchange (HIE), electronic medical records (EMR), and population health?✱

  • Yes
  • No

Voluntary Self-Identification Survey

We invite you to complete this optional survey to help us evaluate our diversity and inclusion efforts. Completion of this form is voluntary on your part and your refusal to complete this form will not subject you to any adverse treatment or otherwise affect your job application. If you choose to complete this form, the information obtained on this form will be kept separate from your name and job application, made available only to personnel on a need-to-know basis, and will not be used to discriminate against or show preference for any applicant. This information will be kept secure and confidential and will be used solely to evaluate our diversity and inclusion efforts and in accordance with applicable law.

• Gender Identity
  • Female
  • Male
  • Gender non-binary
  • Not Listed
  • Prefer not to disclose
• Do you identify as a member of the LGBTQ+ Community?
  • Yes
  • No
  • Prefer not to disclose
• Race/Ethnicity
  • Hispanic or Latine: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
  • Native American/Alaskan Native (not Hispanic or Latino: A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.
  • Indigenous Peoples (Canada)
  • Asian (not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
  • Black or African American (not Hispanic or Latino): A person having origins in any of the black racial groups of Africa
  • Native Hawaiian or Other Pacific Islander (not Hispanic or Latino): A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands
  • White (not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
  • Two or more Races (not Hispanic or Latino)
  • Prefer not to disclose
• Veteran Status
  • I am a veteran
  • I am not a veteran
  • Prefer not to disclose
• Disability
  • Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
  • No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
  • I Don’t Wish To Answer