Physician Award Nomination Form

A letter from a group or individual other than the nominator who can speak to the nominee’s community involvement and/or volunteer work outside of medicine

A letter from a health professional or health administrator in or near the community who can speak to the physician’s medical background, experience, contributions, and scope of practice

- The nominee’s practice interests and the scope of medical care they provide in their community (e.g. obstetrics, cardiac stress testing, geriatrics, etc.)

- How the nominee has played an active role as a member of a multidisciplinary health-care team and/or as a health-care administrator in their community (e.g. Medical Home Model, facility operations, clinic administration, PCN participation, etc.)

- The nominee’s involvement in training medical students, residents, and colleagues (including other health professionals on the team)

- The attraction and retention of other health professionals to the community

- Any programs, education initiatives, innovations, etc. that the nominee has championed or introduced to the community

A letter from a community organization as evidence of community support and impact, and how that commitment and involvement has improved the community, resident experience, and access to health care