2017AMA Foundation Excellence in Medicine Awards

Nomination Form

Check the box of the award for which you are nominating your candidate (please check only onebox)

Dr. Debasish Mridha Spirit of Medicine Award

Recognizes the work of a U.S. physician who has demonstrated altruism, compassion, integrity, leadership, and personal sacrifice while providing quality health care to a destitute, distressed, or marginalized population in an impoverished community.

Dr. Nathan Davis International Award in Medicine

Honors physicians for outstanding international service in the areas of medical practice, medical education or medical research.

Jack B. McConnell, MD, Award for Excellence in Volunteerism

Honors senior physicians (over 55 years old) who are committed to providingmedical care to those without access to health care in the United States.

Pride in the Profession Award

Honors physicians who aid underserved populations in the United States.

The nominee will be invited to attend the Excellence in Medicine Awards celebration and the opening session of the AMA House of Delegates Annual Meeting which will take place on June 9-11, 2017.

How to apply

This form is a downloadable Word.doc that we recommend you save to your computer. Once saved, you can type directly into this form or “cut and paste” your information as you complete the following steps:

  1. Complete sections A& B in full (mandatory). All responses must be completed on this form, using only the space provided for your answers. Note that the text boxes are locked and will not expand.
  2. Submit at least one recommendation letter(mandatory) – section C.
  3. Submit your nominee’s curriculum vitae of no more than 4 pages (mandatory) – section D.
  4. Complete section E(optional) gathering supplemental materials about the nominee such as additional letters of recommendation, media related materials, etc. Supplemental materials, which should not exceed 8 total pages, will not be returned. Each page of your supplemental materials should be in form of an 8.5” x 11” letter-sized piece of paper, with copy on one side. Note that we do not accept DVDs, books, etc, and those submissions will not be considered.
  5. Once complete, sign the nomination form (either print out and sign or electronically by typing in your signature). You are encouraged to email the application to the AMA Foundation at . You can also mail or fax the materials (see instructions at end of document).
  6. All submission materials will not be returned.

Nomination materials must be received at the AMA Foundation Office on or before February 10, 2017, at 5:00pm CST. Applications received after the deadline will not be considered.

We prefer proposals submitted via email but will accept applications submitted via mail or fax. Please choose only one of these methods and do not submit multiple copies of your nomination. We recommend that you use a courier service such as FedEx, UPS, or DHL, rather than USPS First Class, to better ensure a timely arrival (submission instructions on last page).

Cover Page (use Tab Key to move cursor to next text box)

A. Nominee information

Name:(for protocol purposes, indicate appropriate professional designation MD, PHD, MPH, etc.)

Title/Position/Occupation:

Organization:

Mailing address: (if providing a post office box, also include a street address)

City, State and ZIP Code:

Telephone: Fax: E-mail:

Age of nominee:

Does the nominee know he/she is being nominated? yes no

Nominee is a U.S. citizen yes no

If not a U.S. Citizen, nominee is a permanent resident yes no

To be completed onlyfor the Jack B. McConnell, MD Award:

Number of years of volunteerism after age 55

Nominator Information

Name:(for protocol purposes, indicate appropriate professional designation MD, PHD, MPH, etc.)

Title/Position/Occupation:

Organization:

Mailing address:(if providing a post office box, also include a street address)

City, State and ZIP Code:

Telephone: Fax: E-mail:

Signature of nominator:

(If submitting via email, please type name as electronic signature)

General Information

Please verybriefly explain the patient population and primary health initiative in the space provided. You will have the opportunity to expand on this information in Section B of the form.

What activity or initiative(s) has the nominee accomplished that merits this nomination?

What was the role of the nominee in the initiative? (check all that apply)

Personal service/volunteerism Initiater/Founder Educator of medical professionals Educator of patients

Other:

What patient population and geographic area are the primary targets of the nominee’s efforts?

Estimated # of people served by nominee’s primary health care initiative:
Estimated # of years nominee has worked on primary health care initiative:
Estimated amount of time nominee devotes to primary health care initiative: (indicate per week or month)

B.Nomination questions

Respond to the following questions. Substantiate your claims by referring to verifiable sources whenpossible.

  1. Describe the physician you are nominating. How does the individual embody the following values of the medical profession?
  • Leadership and service
  • Excellence
  • Integrity and ethical behavior
  1. Describe the nominee’s volunteer work/projects/health care initiatives. Describe the sustainability of the project(s). How will the initiative(s) be continued after the nominee’s involvement?

3. Who are the patients that the individual nominated serves? Explain how they benefit from the

care provided by the nominee and describe the impact on this population due to the nominee’s efforts.

  1. Provide a brief biographical summary of your nominee.

5. Provide any additional comments or information about your nominee.

C. Submit at least one letter of recommendation (mandatory)

More letters of recommendation are encouraged and will count towards the 8-pages of supplemental materials.

D. Submit Curriculum Vitae (up to 4 pages) (mandatory)

E. Supplemental material (optional)

It is highly encouraged to submit supplemental materials such as additional letters of recommendation, news media – newspaper, newsletter and/or magazine articles, etc, if they are available. Supplemental materials, which should not exceed 8 total pages, will not be returned. DVDs and books will not be considered. Each page of your supplemental materials should be in form of an 8.5” x 11” letter-sized piece of paper, with copy on one side. Supplemental materials will not be returned.

Application checklist

I have answered all the questions on the application form.

I have typed the answers in the space provided.

I have included at least one letter of recommendation.

I have included a Curriculum Vitae of up to 4 pages maximum.

I have submitted optional material (up to 8 pages) such as news articles and additional letters of recommendation, on 8.5” x 11” letter-sized pieces of paper.

Submission Instructions and Deadline

We strongly prefer nominations submitted via email, but will accept applications submitted via mail or fax. Please choose only one of these methods and do not submit multiple copies of your nomination. We recommend that you use a courier service such as FedEx, UPS, or DHL, rather than USPS First Class, to better ensure a timely arrival. Submission materials will not be returned.

Email: Email the AMA Foundationthe completed application form, with an electronic signature, and scan your supplemental information into a PDF or attachment. If your combined files are larger than 7MB and are too large to send in one PDF or Word file, please send in separate emails.

Mail: AMA Foundation

ATTN: Excellence in Medicine Awards

AMA Plaza

330 N. Wabash Ave.

Ste. 39300,

Chicago, IL 60611

Fax:(312) 464-4142

For more information, contact: or call (312) 464-4200.

All nomination materials must be received at the AMA Foundation on or before

February 10, 2017, at 5:00pm CST

Applications received after the deadline will not be considered.

The AMA Foundation is a 501(c)(3) organization. As the philanthropic arm of the AMA, the AMA Foundation improves the health of Americans through support of quality programs in public health and medical education. For more information, visit .