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2022 Imaging Professional for Excellence Nomination
1.
Nominator's Name
2.
Nominator's Phone Number
3.
Nominator's Email Address
4.
Nominee Name
5.
Nominee Phone Number
6.
Nominee Email Address
7.
Job Title and Name of Employer
8.
Credentials
9.
What is the highest level of school they have completed or the highest degree they have received?
Associate Degree
Bachelor Degree
Master Degree
Doctorate
Other (please specify)
10.
How many years of experience does the nominee have as a registered medical imaging or radiation therapy professional?
11.
Please select from the choices below any professional involvement the nominee has engaged in.
Professional Society Memberships
Served on a committee within NCSRT or other Medical Imaging Society or comparable
Held an office for NCSRT or other Medical Imaging Society or comparable
Other (please specify) - please feel free to use this to elaborate on selections above if you like.
12.
Please describe work related professional involvement.
13.
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.
14.
Please describe the nominee's character and how they demonstrate integrity, honesty, and function within their scope of practice.
15.
How does the nominee display commitment to patients, families and their colleagues?
16.
Describe how the nominee interacts with others to assist in their professional growth.
17.
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".
Yes
No
If yes - please make sure you describe how.
18.
In one sentence - please describe what makes this person an outstanding Imaging Professional.
Current Progress,
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