physician-acp-community-health-award

Nominator Name

Nominator Email

Nominator Phone Number

Relationship to Nominee

Nominee Name

Nominee Credential

MD

DO

MBBS

NP

PA

CNM

CRNA

DDS

Practicing Specialty

Department

Location

Nominee Email

Nominee Phone Number

Description of the services being provided to a community in need and the population served (including the location).

What were the results or outcomes of the services being delivered?

What is the length of time and hours that the nominee has been doing this work?

How does this nominee exemplify the Atrium Health core values of caring, commitment, integrity and/or teamwork?

Does the nominee serve on any nonprofit boards / committees or perform other community service?

Has the nominee received any professional awards or recognition during his/her career?

Optional: Please attach supporting documents validating the nominee’s contributions to innovation (i.e. testimonials, letters of support, news articles, journal publications, posters presentations, etc.)

Authentication

Physician - ACP Community Health Award

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