Educator Teaching Students in Auditorium

Nominate a Candidate

To nominate a distinguished medical educator, please complete the following form and attach the nominee’s CV or biographical information. Alternatively, you may download a PDF version of the nomination form.

DEADLINE: September 30th, 2011

About the Nominator

Name:*
Phone:*
Address:*
Fax:
City:*
Email:*
State:*
Zip:*

About the Candidate

Name:*
Phone:*
Address:*
Fax:
City:*
Email:*
State:*
Zip:*
Occupation*:
Job Title*:
Years of Teaching Experience*:
Please attach a curriculum vitae or biography:
Graduate and Post-graduate training and experience (please list):
Professional involvement and offices held (please list):
Society memberships and offices held (please list):
Awards and honors received (please list):
Why is the candidate a distinguished medical educator?
What influences or instruction had the candidate offered to inspire today and change tomorrow?
How had the individual demonstrated profound leadership for tomorrow's medical leaders? Please include any community or volunteer involvement.
Please list one example of how the candidate has shaped the future of tomorrow's leaders. (possible responses might include a specific example of creative instruction or innovation)
How has the individual impacted medical education locally, nationally and worldwide?
In a narrative format, describe your reason for submitting the candidate for consideration for this prestigious award. Include how his/her leadership has impacted you or your organization.