2020 Medical Director of the Year Award - Online Nomination Form

You may nominate an individual for the 2020 Medical Director of the Year Award by completing the information requested below. To aid you in the preparation for your submission/nomination it is recommended that you contact the nominee and ask them to provide you with 12-15 specific activities that support their nomination. Activities should showcase the following characteristics of the nominee in the following areas:  team leader, clinical leader, community involvement and staff education. Nominations are due November 11, 2019.

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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Credentials
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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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E-mail(*)
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IMPORTANT NOTE: The Foundation conducts a blind review of nominations. Please do not include the nominee’s name in the questions below. However, you can refer to the individual as s/he, if needed.

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).

Medical Director Activities
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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.
Examples:
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.).

 

Submitter's Information

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

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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Please provide the country only if it's not the US.

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.