2022 HIVMA Clinical Educator Award Nomination Form

The Clinical Educator Award recognizes HIVMA members who have demonstrated significant achievement in the area of HIV clinical care and provider education. Significant achievement will be based on overall achievement and refer to contributions to the acquisition and dissemination of information on HIV disease that transcend a single institution.

Primary nominators - please complete questions 1, 2, 3, 4, 5 and 6.

Secondary nominators - please complete questions 1, 2, 3 and 8.

Nominations for the 2022 HIVMA Awards are due Monday, June 6th, 2022

Nominators and nominees must be members of HIVMA. Preference will be given to nominations that reflect a broad base of support.

Question Title

* 1. Nominator General Information

First Name

Last Name

Title

Organization

City

State

Relationship to Nominee

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* 2. Nominator Type

A seconding nomination from an HIVMA member other than the nominee will be required. HIVMA staff may be able to help with identifying a seconding nominator. Email HIVMA at info@hivma.org for additional information.

If you are the primary nominator, please enter the full name and email of the secondary nominator below.

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* 3. Nominee Information

First Name

Last Name

Title

Organization

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* 4. Upload Nominee CV

CV should describe with examples how the candidate meets the requirements of the award.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 5. Please discuss how the nominee has demonstrated an impact outside of his/her own institution or outreach to a group with unmet needs.

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* 6. Please discuss evidence of the nominee's originality and innovation in the area of clinical education and/or teaching whether inside or outside of an academic setting.

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* 7. Please share any additional information to support your nomination that was not addressed above.

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* 8. For SECONDARY NOMINATORS - please provide a statement of support describing the nominee's unique contributions to clinical education and the impact that they have had on the field highlighting their original or innovative contributions.

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* 1. Nominator General Information

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* 2. Nominator TypeA seconding nomination from an HIVMA member other than the nominee will be required. HIVMA staff may be able to help with identifying a seconding nominator. Email HIVMA at info@hivma.org for additional information.

Question Title

* 3. Nominee Information

Question Title

* 4. Upload Nominee CV

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* 5. Please discuss how the nominee has demonstrated an impact outside of his/her own institution or outreach to a group with unmet needs.

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* 6. Please discuss evidence of the nominee's originality and innovation in the area of clinical education and/or teaching whether inside or outside of an academic setting.

Question Title

* 7. Please share any additional information to support your nomination that was not addressed above.

Question Title

* 8. For SECONDARY NOMINATORS - please provide a statement of support describing the nominee's unique contributions to clinical education and the impact that they have had on the field highlighting their original or innovative contributions.

* 2. Nominator Type

A seconding nomination from an HIVMA member other than the nominee will be required. HIVMA staff may be able to help with identifying a seconding nominator. Email HIVMA at info@hivma.org for additional information.