The deadline to nominate an individual for the 2018 Medical Director of the Year Award is November 20, 2017.

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2018 Medical Director of the Year Award - Online Nomination Form

Nominee's Personal Information

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The information on this page pertains to the nominee's personal information.

First Name(*)
Please provide your first name.

Last Name(*)
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Title
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Organization
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Address
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City
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State
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Zip
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Country
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Phone
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E-mail(*)
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Nominee's Professional Information

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The information on this page pertains to the nominee's professional background.

Check all that apply

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Experience in Years
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Years of experience as long term care facility medical director.

Service History
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Facilities served and dates of service as medical director (e.g., Golden Age NH 2001-06).

Team Leader Activities
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List top 3 - 5 activities that demonstrate ability as team leader (e.g., established wound care team).

Clinical Leader Activities
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List top 3 - 5 activities that demonstrate ability as clinical leader (e.g., implemented practice guideline on falls prevention).

Community Involvement Activities
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List top 3 - 5 activities that demonstrate community involvement (e.g., hold monthly advance directive 'clinics' at area senior center).

Staff Education Activities
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List 5 -10 educational activities that demonstrate ability to educate staff - such as inservice topics, state or national presentations, etc.

 

Submitter's Information

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The information on this page pertains to you as the submitter.

First Name(*)
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Last Name(*)
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Title
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Organization
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Address
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City
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State
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Zip
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Country
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Phone
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E-mail(*)
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Validation Check

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The information on this page pertains to the security and validation of this submission.

Captcha(*)
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Type the four lower case characters shown in the box above on the left into the box on the right and click Submit. You may click the Refresh link above as many times as you need to until you're confident you see the letters clearly.