The Dr. S. Lawrence Librach Award for Palliative Medicine in the Community Survey

This award is presented annually to a physician who demonstrates excellence and leadership in palliative care and advances palliative care in their communities through mentorship of family physicians.

To the considered for this award, the nominee must:

Be a physician licensed to practice in the Province of Ontario
Work primarily in community settings (non-institutional)
Demonstrate excellence in patient care
Demonstrate leadership in advancing palliative care in community settings
Be recognized by their peers as a mentor

1.Nominator Contact Information(Required.)

Name

Organization Name

Organization Address

Address 2

City/Town

Province

Postal Code

Email Address

Phone Number

2.Nominee Contact Information(Required.)

Name

Organization Name

Organization Address

Address 2

City/Town

Province

Postal Code

Email Address

Phone Number

3.This nomination is supported by the following two (2) individuals:

Name of first individual

Email of first individual

Name of second individual

Email of second individual

4.In 400 words or less, please tell us how the nominee demonstrates excellence in patient care.

5.In 400 words or less, please tell us how the nominee demonstrates leadership in advancing palliative care in community settings (home care, hospice care, long-term care)

6.In 400 words or less, please tell us how the nominee demonstrates leadership in palliative care education and mentoring for family physicians.

7.Please use this space to share any other information you feel supports your nomination.