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CACN Early Career Achievement Award
Nomination Form
This award recognizes an early-career pediatric neurologist who has demonstrated outstanding contributions to clinical care, research, education, or leadership. (awarded every 2 years)
NOMINEE INFORMATION
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1.
Full name
(Required.)
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2.
Position/Title
(Required.)
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3.
Institution/practice
(Required.)
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4.
City and Province
(Required.)
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5.
Email
(Required.)
NOMINATOR INFORMATION
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6.
Nominator full name
(Required.)
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7.
Email
(Required.)
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8.
Relationship to nominee
(Required.)
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9.
Confirmation of eligibility
(Required.)
The nominee is within seven (7) years of beginning independent practice as a pediatric neurologist (excluding parental, medical, or other approved leaves).
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10.
Confirmation of criteria met
Check all that apply (the nominee should show meaningful impact in at least one domain).
(Required.)
Evidence of meaningful impact in at least one domain (clinical program development, research productivity, or
education)
Demonstrated leadership or initiative (e.g., leading a clinic, program, or project)
Engagement at a regional or national level (e.g., involvement with CACN or CNSF)
Clear trajectory for future contribution and leadership
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11.
Nomination statement
Summarize why this nominee deserves the award (maximum 250 words)
(Required.)
12.
Document upload
Upload the nominee's CV (if available)
Choose File
No file chosen
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13.
Names of two (2) other references
(Required.)
Name 1
Email 1
Name 2
Email 2
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14.
Submission
(Required.)
Nominator signature (type full name)
Date
