2023 SPAP PA of the Year

SPAP Pediatric PA of the Year Nomination Form

Please type or print legibly and complete the following information:

THE DEADLINE FOR APPLICATION IS APRIL 7th, 2023.

PLEASE ENSURE THAT THE NOMINATION FORM IS COMPLETED BEFORE SENDING IT.

Current SPAP Board of Directors members are ineligible for nomination.
Nominees and nominators are not required to be members of SPAP.
Once nominated, SPAP will request a current CV from nominees to complete the nomination process.

FULL NAME OF NOMINEE AND CREDENTIALS: *

EMAIL ADDRESS OF NOMINEE: *

BEST PHONE NUMBER TO CONTACT NOMINEE: *

NOMINEE’S PRIMARY PLACE OF EMPLOYMENT: *

YOUR NAME AND CREDENTIALS: *

YOUR EMAIL ADDRESS & RELATIONSHIP TO NOMINEE AND HOW LONG YOU HAVE KNOWN THE NOMINEE *

0/300 words

Does the PA nominee have a primarily pediatric patient population (>70% patients under 18y): *

Yes

How many years of experience in pediatrics does the nominee have: *

1 to 3 years

3 to 5 years

5 to 10 years

10+years

Please answer each category below in as much detail as possible. Scores for each nominee will be calculated according to the number of examples provided and the level of commitment documented. We will also be asking the nominee for their CV for further information.

In 300 words or less, describe the nominee’s advocacy and community service efforts as a physician assistant and/or towards the pediatric field. *

0/300 words

In 300 words or less, describe the nominee’s participation in education/preceptorship opportunities. This can include educating PA students as well as involvement in educational opportunities at conferences and other events for PAs. *

0/300 words

In 300 words or less, describe examples of the nominee’s participation in research and/or QI events for PAs. *

0/300 words

In 300 words or less, describe how the nominee demonstrates a commitment to excellence in pediatric healthcare. *

0/300 words