CACN Award for Excellence in Clinical Care and Advocacy Nomination Form Survey

This award recognizes a pediatric neurologist, at any stage of their career, who has demonstrated outstanding clinical excellence and has made meaningful contributions to improving the quality, delivery, or accessibility of care for children with neurological conditions.
Awarded every 2 years

NOMINEE INFORMATION

1.Full name(Required.)

2.Position/Title(Required.)

3.Institution/practice(Required.)

4.City and Province(Required.)

5.Email(Required.)

NOMINATOR INFORMATION

6.Nominator full name(Required.)

7.Email(Required.)

8.Relationship to nominee(Required.)

9.Confirmation of eligibility(Required.)

Open to academic and community-based pediatric neurologists at any career stage, across diverse practice
settings

10.Confirmation of criteria met
Check all that apply. Must meet at least three of five criteria.(Required.)

Excellence in patient care, delivered in a respectful, culturally safe manner responsive to diverse identities, needs,
and lived experiences of patients and families

Contributions to improving quality of care (e.g., care pathways, safety initiatives, reduced wait times), including
reducing inequities in outcomes or access

Demonstrated impact on access to care for equity-deserving populations (e.g., marginalized, Indigenous,
underserved, rural, or medically complex)

Evidence of patient- and family-centered care and advocacy

11.Nomination statement
Summarize why this nominee deserves the award (maximum 250 words)(Required.)

12.Document upload(Required.)

Upload the nominee's CV

No file chosen

13.List examples of program, quality, or advocacy impact (list the three most significant)(Required.)

Example 1

Example 2

Example 3

14.Names of two (2) other references(Required.)

Name 1

Email 1

Name 2

Email 2

15.Submission(Required.)

Nominator signature (type full name)

Date