2019 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.

Nominations for the 2019 HIVMA Leadership Awards are due May 1st. Nominators and nominees must be members of HIVMA. Preference will be given to nominations that reflect a broad base of support.

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* 1. Nominator General Information

Title

First Name

Last Name

Organization

Relationship to Nominee

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* 2. Nominator Type

One seconding nomination from an HIVMA member other than the nominee is required. Standing HIVMA Board and Award Committee members are not eligible.

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

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* 3. Nominator Contact Information

Street Address

Address Line 2

City

State

Zip

Phone

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* 4. Nominee General Information

Title

First Name

Last Name

Organization

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* 5. Upload Nominee CV

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

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

Choose File

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* 6. 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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* 7. Please discuss how the nominee has demonstrated excellence in teaching. Include a description of what audience was affected by the clinician educator and how they were affected-- whether inside or outside of the usual academic setting.

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* 8. Please discuss evidence of the nominee's originality and innovation in the area of clinical education. Please include no more than two examples of a curriculum, manuscript, book chapter or other educational materials that the nominee has developed

2019 HIVMA Clinical Educator Award Nomination Form

Question Title

* 1. Nominator General Information

Question Title

* 2. Nominator Type

One seconding nomination from an HIVMA member other than the nominee is required. Standing HIVMA Board and Award Committee members are not eligible.

Question Title

* 3. Nominator Contact Information

Question Title

* 4. Nominee General Information

Question Title

* 5. Upload Nominee CV

Question Title

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

Question Title

* 7. Please discuss how the nominee has demonstrated excellence in teaching. Include a description of what audience was affected by the clinician educator and how they were affected-- whether inside or outside of the usual academic setting.

Question Title

* 8. Please discuss evidence of the nominee's originality and innovation in the area of clinical education. Please include no more than two examples of a curriculum, manuscript, book chapter or other educational materials that the nominee has developed

Question Title

* 9. Please discuss the nominee's greater impact on the field of HIV Medicine.

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

Question Title

* 1. Nominator General Information

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* 2. Nominator TypeOne seconding nomination from an HIVMA member other than the nominee is required. Standing HIVMA Board and Award Committee members are not eligible.

Question Title

* 3. Nominator Contact Information

Question Title

* 4. Nominee General Information

Question Title

* 5. Upload Nominee CV

Question Title

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

Question Title

* 7. Please discuss how the nominee has demonstrated excellence in teaching. Include a description of what audience was affected by the clinician educator and how they were affected-- whether inside or outside of the usual academic setting.

Question Title

* 8. Please discuss evidence of the nominee's originality and innovation in the area of clinical education. Please include no more than two examples of a curriculum, manuscript, book chapter or other educational materials that the nominee has developed

Question Title

* 9. Please discuss the nominee's greater impact on the field of HIV Medicine.

Question Title

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

* 2. Nominator Type

One seconding nomination from an HIVMA member other than the nominee is required. Standing HIVMA Board and Award Committee members are not eligible.