2024 Emergency Medicine Wellness Center of Excellence Award Form

Nominator Information

The completed nomination form, nominee’s curriculum vitae and letters of support must be submitted electronically, preferably in Word format, no later than March 12, 2024, to be considered by the Emergency Medicine Wellness Section. Up to three letters of support for the nomination may also be submitted. Letters of support are greatly encouraged and are at the discretion of the nominator. The letters of support should explain why the nominee merits the award and specifically relate the nominee’s background to the award criteria. Please also submit any letters of support in Word format.

Receipt of each nomination will be confirmed by e-mail. Please follow up with Amanda Pairitz-Campo, if you do not receive a confirmation.

This form must be completed entirely. Do not indicate "see C.V."

Nominated by

Date submitted

Street address

City

State

Zip

Email address

Nominee

Name of nominee

Telephone

Street address

City

State

Zip

Team Member Name(s) and Title(s) - if applicable

Please state why this person or organization should be honored with this award, based on the indicated Award criteria.

Do any of your team members hold an ACEP officer position (national or chapter)? Please list team member's name and position(s) held.

Committees (National, Local/Name of Committee and Length of Service)

Are there any notable wellness or resilience programs that you would like to mention?

Please list any presentations or programs your group has participated in. Please include the type of program, audience size, and outcome.

Upload CV (of nominee or lead director/faculty)

Upload letter(s) of support.

Note: You can upload multiple letters of support after clicking the "Choose Files" button, simply select multiple files once the window opens.

Please list any research initiatives your team has participated in.

Word verification An error has occurred while getting captcha image