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Physician - ACP Community Health Award
Physician - ACP Community Health Award
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.)
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