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Public Health Award Nomination Form

Public Health Award Nomination Form

Make your nomination today by completing all of the fields on this form. Please be sure to review the list of eligibility requirements for candidates below:

 

  • Must be a family physician
  • Is a member of the Pennsylvania Academy of Family Physicians
  • Is in good standing in their medical community
  • Can effectively represent the specialty of family practice and the PAFP in public speaking
  • Has demonstrated leadership and engagement in either a traditional public health organization or population and community health
  • Is actively engaged within their health system or community
  • Efforts focused on health equity as well as diversity and inclusion

Tell us why this physician should win the PAFP’s Public Health Award. Provide as much information as possible below:

 

 
NOMINEE INFORMATION:
 
Physician Name:  
 
Practice Name:  
 
Practice Address:  

City

State

Zip Code
 
Phone No.:  
 
 
YOUR INFORMATION:
We need information about you to process and confirm your submission. We will never share this information with outside parties, and we will contact you only about this nomination.
 
Name:  
 
Address:  

City

State

Zip Code
 
Phone No.:  
Email:  
 
How did you hear about this award:
 
 
Tell us why this physician deserves to win the PAFP Public Health Award. Provide as much information as possible below: