Exit this survey 2015 NJAFP Family Physician of the Year Award Question Title * 1. Enter your contact information. Name Address Phone Email Question Title * 2. Specify your occupation. Question Title * 3. Enter the contact information for the nominee. Name Address Phone Email (if known) Question Title * 4. Describe how the nominee provides the community with compassionate, comprehensive and caring medical services on a continuing basis. Question Title * 5. Please describe how the nominee is directly and effectively involved in community affairs and activities that enhance the quality of life in his/her home area. Question Title * 6. Describe how the nominee provides a credible role model, emulating the family physician as a healer and human being to his/her community. Question Title * 7. Has the nominee been in Family Medicine in New Jersey for at least 10 consecutive years? Yes No I don't know Question Title * 8. Is the nominee Board Certified in Family Medicine? Yes No I don't know Question Title * 9. Is the nominee a member in good standing in his/her community? Yes No I don't know Question Title * 10. In 500 words, please tell us why you consider this physician a nominee for Family Physician of the Year. All nominations will be verified and we will notify you if we need additional information. Thank you for participating! Done