ACDIS 2020 Professional of the Year Nomination Survey

1.Your Contact Information(Required.)

Name

Facility or company name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

2.Nominee's Contact Information (if not nominating yourself)

Name

Facility or company name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

3.Please provide a short bio (one paragraph) for your nominee (Please start with their full name, credentials, job title, facility name, city, state and then include some description of their professional career and educational history. Examples of professional bios can be seen on ACDIS’ Boards and Committees pages.)

4.Which award would you like to apply for?(Required.)

Professional of the Year

Recognition of Professional Achievement

Excellence in Provider Engagement

Rookie of the Year

5.Please list three reasons for nominating this individual?

6.Please upload your nominee's resume, CV, or provide a link to an online professional profile (if available)

Please use PDF or DOC formats and include a photo of the nominee if available.

No file chosen

7.Please provide an additional relevant information about your nominee or your program to paint the picture of why they are a deserving candidate.