2025_Osteopathic Family Medicine Educator of the Year Award Application

ACOFP Osteopathic Family Medicine Educator of the Year Award

Submission Deadline: September 15, 2024
The Osteopathic Family Medicine Educator of the Year Award honors an individual who exemplifies the osteopathic family medicine profession’s highest standards of excellence in teaching and has made significant, commendable, and long-standing contributions to the academic advancement of osteopathic students, residents, and the osteopathic profession.

Award qualifications include:
- Must be an active ACOFP member in good standing.
- Must be currently certified in family medicine by the American Osteopathic Association (AOA) or the American Board of Medical Specialists (ABMS).
- Must have no current restrictions on any medical licenses at the time of application.
- Must be actively involved in osteopathic education and demonstrate commitment to the osteopathic philosophy and profession.
- Must have a significant impact on students, peers, academic institutions, the osteopathic profession, and/or the community.
- Must demonstrate compassion and leadership in their role as an educator.
Award requirements include:
- Submission of one letter of support from the nominator.
- Submission of one letter of support from the nominee's academic institution.
Nominator Information
Nominator Name *
Phone Number*
Email*
example@example.com
Nominee Information
Nominee Name*

First NameLast Name
Suffix
Designation*
Academic Institution*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Is the nominee currently certified in family medicine by the AOA or ABMS?*

YesNo
List of current active state medical licenses of nominee*
Does the nominee have any current restrictions against their medical licenses?*

YesNo
If yes, please provide an explanation:
Has the nominee had any restrictions within the past two years against their medical licenses?*

YesNo
If yes, please provide an explanation:
C/V File Upload*

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Letter of Support from Nominator File Upload*

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Letter of Support from Academic Institution File Upload*

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Additional Letter of Support (Optional) File Upload

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Professional Head Shot Photo Upload (high-resolution images only) *

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By signing below, I certify that, to the best of my knowledge, the information provided for the nominee in this application is true and accurate.
Signature*

Clear
Date*

MonthDayYear
Date
All completed submissions must be received by September 15, 2024. Applicants will be notified of the selection results via email no later than December 1, 2024.

Please contact Tina Burk at tinab@acofp.org if you have any questions.
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ACOFP Osteopathic Family Medicine Educator of the Year Award

Nominator Information

Nominee Information