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Award Nomination

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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

Department Director

Applicant

Full Name*

Credentials*

Department*

Institution*

Street*

City*

State*

Zip Code*

Phone*

Email Address*

Nominee

Hospital Public Relations Department

Contact Name*

Contact Email*

Award Recipient

Full Name*

Credentials*

Email Address*

Award Designation*

Residency Program

Department

Award Designation*

Lifetime Researcher

Established Researcher

Rising Star Researcher

Award Designation*

Young Physician

Resident

Practice Site*

Residency Graduation Year*

Post-Graduate Year*

Residency Program*

Do you plan to practice in New York?*

Have you previously attended the Leadership & Advocacy Conference*

Identify the Reasons Why You Would Benefit From Attending the ACEP Leadership and Advocacy Conference*

Please detail how this nominee has significantly impacted your institution. (information will be published as submitted on the New York ACEP website and in your local community press release)*

What makes this nominee's contribution different from others in your institution?*

Recipient Narrative Bio (Please do not submit a CV)*

Describe Your Interests in Political Action, Advocacy and/or Leadership*

Describe Prior Leadership and/or Service Experiences*

Department*

Institution*

Residency Program or Department*

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 Picture (minimum 350x450)*

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.):*

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