2014 Award of Excellence
I would like to nominate the following AVIR member as a candidate for the 2014 Award of Excellence
Nominee (Candidate) Information:
Name of Candidate: ______Credentials:______
Home Address:______
Home Phone: ______
Place of Employment: ______
Work Address: ______
Work Phone: ______Work Fax:______
IMPORTANT: Is candidate currently aware that you have placed their name in nomination forthis award? (This will help us determine how to proceed when we contact them for information and interview.)
Yes ?No?
Nominated by:
Name: ______
Work Position: ______
Home Address: ______
Home Phone: ______
Place of Employment: ______
Work Address: ______
Work Phone: ______
Work Fax: ______
Relationship to Candidate (How do you know this person?): Co-Worker/ Peer/ Supervisor
For how long?: ______
______
Signature of Nominator
Date: ______
Submission Deadline: December 01, 2013
2014 Award of Excellence
Nomination Questionnaire
Your response to these questions will help us get to know your candidate. Please feel free to attach a separate sheet if you do not have enough space to complete your response to any question below.
What contributions does this candidate make to the Interventional Radiology department?______
Describe candidate’s competency and professionalism.______
Describe candidate’s interaction with patients and their families (include patient education).
______
Describe contributions candidate makes outside of patient care, i.e., to department’s quality
assurance program; development of policies and procedures; staff education; cost saving
ideas; etc.
______
Describe candidate’s interaction with department personnel (radiologists, peers, ancillarystaff and supervisors).
______
Submission Deadline: December1, 2013
2014 Award of Excellence
Nomination Questionnaire
Describe candidate’s working relationship with hospital nurses, physicians, and allied
health professionals. Include any work candidate does on hospital committees or projects.
______
Describe contributions candidate makes to the community, (i.e., health fairs, CPR instructor,
etc.).
______
Describe other reasons you feel this candidate should receive this award - tell us how this
candidate “goes the extra mile.”
______
______
You may include one letter of recommendation from each of the following: physician; technologist; coworker/peer; and supervisor/radiology director.
Letters may accompany this nomination application ormay be sent directly to the AVIR office address listed below.
Thank you for nominating this candidate. We may call you for some additional background on your
nominee.
Submission deadline is December01, 2013.
Mail to: AVIR Headquarters
2201 Cooperative Way, Suite 600 • Herndon, VA 20171
OR you can SCAN and EMAIL to: or any of the Board Members
Please call if you have any questions: Phone: (571) 252-7174