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* 1. Nominator's Name

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* 2. Nominator's Phone Number

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* 3. Nominator's Email Address

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* 4. Nominee Name

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* 5. Nominee Phone Number

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* 6. Nominee Email Address

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* 7. Job Title and Name of Employer

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* 8. Credentials

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* 9. Assign percentage of time to each category

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* 10. What is the highest level of school they have completed or the highest degree they have received?

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* 11. How many years of experience does the nominee have as a registered medical imaging or radiation therapy professional?

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* 12. Please select from the choices below any professional involvement the nominee has engaged in.

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* 13. Please describe work related professional involvement.

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* 14. Please describe how the nominee positively promotes and advances the Medical Imaging and Radiation Therapy profession in their practice setting and/or in the community.

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* 15. Please describe the nominee's character and how they demonstrate integrity, honesty, and function within their scope of practice.

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* 16. How does the nominee display commitment to patients, families and their colleagues?

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* 17. Describe how the nominee interacts with others to assist in their professional growth.

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* 18. Do you consider your nominee to radiate energy and truly make a difference to overall outcomes in your practice setting?  If yes, please explain "why".

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* 19. In one sentence - please describe what makes this person an outstanding Imaging Professional.  

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