Quality of health information on the internet (QHII/HWR)
Application to rate health websites

Health Improvement Institute is seeking knowledgeable health professionals to refine evaluation criteria and/or to rate internet health websites. The Institute depends on volunteers but may be able to offer an honorarium to qualified individuals for participating in the project.

• If you are interested in rating health websites, please fax this completed form to 301-320-0978 and also submit a brief (1-2 pages) resume or biographical sketch highlighting relevant qualifications and experience.
• If you have any questions, please call the Awards Coordinator at 301-320-0971 or email hii@hii.org.

Please complete and fax with brief biography to 301-320-0978 - page 1 of ____

Name:	_____________________________________________________________________________
Organization:	_____________________________________________________________________________
Position/Title:	_____________________________________________________________________________
Address:	_____________________________________________________________________________
	_____________________________________________________________________________
Telephone:	__________________________ Fax: ______________________________________________
Email:	_____________________________________________________________________________

Please complete below and sign at end

For Q1.1 and Q1.2, Please check the one category that is most applicable:

1.1 Present organization:	1.2 Present role:
oAccrediting/Awards/Ratings organization	oAdministrator (of institution/center,etc)
oConsulting company(or research institute)	oConsumer/advocate
oConsumer advocacy organization	oConsultant to web publisher
oDrug/device manufacturer	oEducator/trainer
oGovernment/regulatory agency	oHealth care practitioner
oHealthcare facility (e.g. hospital)	oLibrarian / Information specialist
oHealth plan/insurer	oPublic relations/communications
oHealth professional association (e.g.,AMA,ANA)	professional
oHealth science school (university)	oRegulator (government)
oHealth trade association (e.g., AHA, BIO,	oSocial scientist
PhARMA)	oWebsite publisher/content provider
oIndependent consultant/Individual	oOther, please specify below:
oLaw firm	________________________________________
oMedia (eg.TV, radio)
oPublisher (including website)
oVoluntary health association (e.g., Red Cross)
oOther, please specify below:
________________________________________
2. In the past 5 years, in which of the following	3. Adverse professional events - In the last
ways have you been involved in designing,	5 years, have you been, or are you currently
using, or evaluating health websites?	involved with any event that could call
Check all that apply	into question your suitability to rate websites
oAdviser, trainer of consumers/professionals	(e.g., adverse action regarding quality of care
on use of websites	professional conduct, research integrity, etc)?
oAdvocate	o Yes; explain below oNo
oDesigner of website
oMember of committee that formulated website	4. Other relevant qualifications or experience,
code of conduct, evaluation criteria, etc	explanations of adverse professional events,
oRater/evaluator of websites	comments, etc.
oResearcher of websites
oUser of health websites
oWebmaster
oWebsite content producer/publisher
oOther, please specify below:
________________________________________

Signed: ______________________________________________ Date: ____________________

Printed name: ___________________________________________________________________

Form HWR-0562;ID...; version 1.2; revised January 16, 2006