PNW Spirit Award Nomination Form

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* 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

Community Advocacy & Integrity

Physician Wellness

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* 2. Are you nominating an Individual or a Group?

An Individual

a Group

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* 3. Please provide the following information:

Name of Individual or Group being nominated

Company, if applicable

City/Town

Email Address

Phone Number

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* 4. Is the Individual or Group aware of this nomination?

Yes

No

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* 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.

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* 6. Do you have supporting materials to provide? If so, please email to cenns@pnwdivisionbc.ca

Yes

No

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* 7. Are you able to provide a photo of the Nominee for media communications? If so, please email to cenns@pnwdivisionbc.ca

Yes

No

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* 8. Nominator Name(s)

Name

Company, if applicable

City/Town

Email Address

Phone Number

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* 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.