Please answer the following questions:

1. Please state your purpose for attending this program.

2. What delivery system improvement is your hospital undertaking and how will this program help manifest the delivery system improvement?

Approval by CEO or Designee

Name and Title of CEO or Designee: _______________________________________

CEO or Designee’s Signature: _____________________________________________

70 Washington Street Suite 215

Oakland, CA 94607

510.874.3401 (Ph) 510.874.7111 (fax)

Date: __________________

Name of Scholarship Applicant: _______________________________________

Applicant’s Position/Job Title: __________________________________________________

Applicant’s CAPH Hospital/Health System: _______________________________

Applicant’s Phone: _____________________ Applicant’s Email: ______________________

Name of IHI Program for which you are seeking scholarship support:

____________________________________________________________________

Program Dates:___________________ Program Cost: _$__________________

_____________________________________________________________________________________________________

CEO Approval for Kaiser Permanente IHI Scholarship Fund

Please return this form by fax to Abby Gonzalez at 510-874-7111 or email to agonzalez@caph.org with the subject “IHI Scholarship-CEO Approval”

A 501(c)(3) research and education affiliate of the California Association of Public Hospitals and Health Systems