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About
Board of Directors & Councillors
Awards
Committees
Calendar
Advocacy
Workplace Violence Prevention Alliance
Advocacy Day
New York Emergency Medicine Political Action Committee
Action Alerts
Events
ED Practice Innovations Conference
Medical Student Symposium
EM Resident Career Day
Resident Research Conference
Scientific Assembly
Member Benefits
Online CME
Leadership and Development Fellowship
Academy of Clinical Educators
Opportunities for Women in Leadership
Speaker Directory
Resources
Join New York ACEP
Empire State EPIC
Current Issue
Previous Issues
Newsletter Advertising
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Award Nomination
"
*
" indicates required fields
Award
Advancing Emergency Care Award
Edward W. Gilmore Lifetime Achievement Award
Leadership in Government Award
Michael G. Guttenberg Outstanding Contribution to EMS Award
JoAnne Tarantelli Outstanding Contribution to Emergency Medicine in New York Award
National Leadership Award
Physician of the Year Award
Exemplary Commitments to Physician Well-Being Award
Outstanding Researcher Award
Young Physician and Resident Leadership & Advocacy Award
New York ACEP Unsung Hero of Emergency Medicine Award
Nominator
Applicant
Full Name
*
Credentials
*
Department
*
Institution
*
Street
*
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
Nominee
Full Name
*
Credentials
*
Award Designation
*
Residency Program
Department
Award Designation
*
Lifetime Researcher
Established Researcher
Rising Star Researcher
Award Designation
*
Young Physician
Resident
Do you plan to practice in New York?
*
Yes
No
Have you previously attended the Leadership & Advocacy Conference
*
Yes
No
Identify the Reasons Why You Would Benefit From Attending the ACEP Leadership and Advocacy Conference
*
Describe Your Interests in Political Action, Advocacy and/or Leadership
*
Describe Prior Leadership and/or Service Experiences
*
Department
*
Residency Program or Department
*
Institution
*
Street
*
City
*
State
*
Zip Code
*
Contact Name
*
Phone
*
Email Address
*
Mission
*
Vision
*
Programs or Systems in Place to Facilitate Mental Health & Emotional Well-Being
*
Operational Processes in Place to Improve the Physician Clinical Experience
*
Policies to Ensure Diversity and Gender Equity
*
Safe and Physician-centric Environmental Provisions
*
Efforts to Foster Community
*
Educational Experiences Offered
*
Programs or Projects in Place That Should be Highlighted
*
Attach Current CV
*
Max. file size: 128 MB.
Attach Letter of Support
*
Max. file size: 128 MB.
Attach Current CV Demonstrating Selection Criteria
*
Max. file size: 128 MB.
Attach Cover Letter (On behalf of the candidate or by the candidate)
*
Max. file size: 128 MB.
Attach Letter of Support (From department chair or research mentor)
*
Max. file size: 128 MB.
Please state why this person should be honored with this award, based on criteria for this award:
*
ACEP Offices Held (New York ACEP and National ACEP):
*
Committees (New York ACEP/National ACEP, Name of Committee and Length of Service):
*
Other Emergency Medicine-Related Services (Title and Length of Service):
*
Other Activities of Special Merit (Civic, Institution, etc.):
*
