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PNW Spirit Award Nomination Form
1.
Please select the PNW Spirit Award that you would like to nominate an individual or group for.
Excellence in Team-Based Care
Innovations in Global Health
Innovations in Digital Healthcare & Technology
Lifetime Achievement
Physician Leadership
Rural Family Practice
Excellence in Primary Care - Family Physicians
Excellence in Primary Care - Nurse Practitioners
Excellence in Primary Care - Allied Health Providers
Innovations in Primary Care
Excellence in Partnership
Excellence in Research
Excellence in Specialty
PNW Community Impact
Physician Wellness
2.
Are you nominating an Individual or a Group?
An Individual
a Group
3.
Please provide the following information:
Name of Individual or Group being nominated
Company, if applicable
City/Town
Email Address
Phone Number
4.
Is the Individual or Group aware of this nomination?
Yes
No
5.
Please provide a summary highlighting the reasons why this individual or group should be considered for the award. Please include all relevant information in regards to initiatives, goals and objectives, target audience, expected outcomes, successes, and any supporting materials to support your nomination.
6.
Do you have supporting materials to provide? If so, please email to cenns@pnwdivisionbc.ca
Yes
No
7.
Are you able to provide a photo of the Nominee for media communications? If so, please email to cenns@pnwdivisionbc.ca
Yes
No
8.
Nominator Name(s)
Name
Company, if applicable
City/Town
Email Address
Phone Number
9.
Thank you for your nomination! Please note that you may be contacted by a member of the Pacific Northwest Division of Family Practice. Please provide any additional contact information or details we may require.
Current Progress,
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