Family Medicine Shining Star Nomination Form - Deadline is August 1.
The IAFP Public Relations Task Force reviews all nominations to determine the recipient. There is no requirement to give the award every year.
About you
Your Name
*
Email Address
*
Phone number
About your nominated IAFP member family physician
Only IAFP members can be considered for the award
Name
*
Practice Name
*
City
*
Important details
How long have you known this doctor?
This family doctor cares for
Me
My spouse or significant other
My child(ren)
Other family members
Friends
Co-workers
None of the above
Do you work with your nominee?
*
Please Select
Yes
No
Did at one time
How do you know this family physician?
Please tell us more about your nominee. Your answers to all the questions below will serve in place of a formal support letter.
So please provide as much detail as you can.
How does this doctor provide exceptional and compassionate care?
How does this doctor improve the health of a community (using a broad definition of the word community)?
How does this doctor serve as a role model for other health care professionals?
How does your nominee champion family medicine's values in a leadership role?
Please add a few comments about the doctor's special attributes that you feel should be considered.
You can attach any supporting documents/articles/photos here. This is optional, not required.
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In checking this box I give consent for IAFP staff to contact me about my nomination.
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