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Test form - Academic
Nomination Form - Academic Excellence
Your Information:
*
indicates required fields
Click here
to see how we may share your nomination.
If you would like to save and continue the nomination later, please click the 'Save and Continue Later' button at the bottom of the form.
Your Name
*
Today's Date
*
MM slash DD slash YYYY
Your email address
*
Your phone number
*
Are you a Resident or Fellow Physician
*
Yes
No
Credentials (if applicable, ie: MD, DO, NP, PA)
Your Submission:
Author(s) Name
*
Primary Author
*
Author email address
*
Author phone number
*
Medical group or academic institution
*
Location
*
Author state
*
Select:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
National System Teams
Other
Article title
*
Publication Venue or Journal
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Date published
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Month
Day
Year
Upload article here (.pdf only)
*
Accepted file types: pdf, Max. file size: 50 MB.
Award Category
*
Clinical Research
Medical Humanities
Health Equity Research
Practice Innovation
Click Here
for a description of the categories.
Please provide a high level executive summary of article in 100 words or less
*
Please Summarize Relevance to Patient Care (50 word count recommended)
*
If you would like to save and continue the nomination later, please click the 'Save and Continue Later' button below
This will display a page with the link to use to continue your submission.
Enter your email address and click 'Send Link' to have the link sent to you in an email.
Without this link it is not possible to resume your submission.
Phone
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