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.

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