"*" indicates required fields Basic InformationYour name:* First Last Suffix Your title:* Your institution:* Your email address:* Name of nominee:* First Last Suffix Nominee's institution:* Nominee's title:* Nominee's email address:* Has the nominee completed at least two years of surgical residency?* Yes No The nominee is not eligible for the award at this time.Short EssaysPlease write about one paragraph on each of the following:Why do you think the nominee deserves this award?*How has the nominee demonstrated passion and enthusiasm for teaching?*How has the nominee demonstrated a commitment to maintaining a positive, productive learning environment?*How has the nominee demonstrated being able to provide effective feedback to learners?*Please give an example of the nominee role modeling professionalism.*Please complete the following:Please list any education or teaching awards the nominee has received.*Please list the nominee’s education-related activities (e.g., lectures, programs, presentations, curricula, innovations for teaching or assessment, education-related research).*Please list the nominee’s leadership roles in courses or groups related to surgery and surgical education, including involvement in national committees related to surgical education.*File UploadsPlease upload the nominee's CV*Accepted file types: pdf, Max. file size: 512 MB.Please upload a teaching statement from the nominee about their passion, enthusiasm, and commitment to teaching.*Accepted file types: pdf, Max. file size: 512 MB.Please upload a letter of recommendation from a learner.*Accepted file types: pdf, Max. file size: 512 MB.Please upload documentation of teaching competency in the form of an aggregate evaluation report (from MedHub, New Innovations, etc) from learners over the past year.*Accepted file types: pdf, Max. file size: 512 MB.EmailThis field is for validation purposes and should be left unchanged.
