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Nominee's Personal Information
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Nominee's Professional Information
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Certified Medical Director (CMD)
Minimum 3 years experience as a Medical Director
Experience as an Attending Physician in long term care setting
Years of experience as long term care facility medical director.
Facilities served and dates of service as medical director (e.g., Golden Age NH 2001-06).
Please include a list 7-10 examples of activities that the nominee leads in the following areas: team leader, clinical leader, community involvement and staff education.
Team Leader Activites (e.g., established wound care team).
Clinical Leader Activities (e.g., implemented practice guidelineon falls prevention).
Community Involvment Activities (e.g., hold monthly advance directives 'clinics' at area senior center).
Staff Education Activities (e.g., inservice topics, state or national presentations, etc.).
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Please provide the country only if it's not the US.
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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.
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