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Nomination Form for 2010 Kenneth J. Ryan, MD, Physician Leadership Award

Nomination Form for 2010 Kenneth J. Ryan, MD, Physician Leadership Award

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Published by: prch55 on Aug 03, 2010
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2010 Kenneth J.

Ryan, MD, Physician Leadership Award Nomination Instructions and Application Nomination Deadline-December 18th, 2009 _______________________________________________
Nomination Instructions: Criteria: Must be an obstetrician and gynecologist
1. 2.

Save this document to your computer before proceeding. Fill out Kenneth J. Ryan, MD, Physician Leadership Award 2010 Application Form.
a.

Type in the gray boxes provided on the application.
i. ii.

Must provide contact information for both the nominee and nominator. Write a description in 500 words or less of the nominee and her/his longstanding work to improve reproductive health in: (1) research, (2) education, (3) clinical service, and (4) advocacy over the course of her/his career. Submit nominee’s CV.
1.

iii.

To enter the CV into the application, cut and paste from a word document or you may email it with the application as an attachment.

3.

When application is complete, please email the application as an attachment no later than December 18th, 2009, to: Penny Vick, MPH Education and Research Senior Associate Physicians for Reproductive Choice and Health Email: penny@prch.org Phone: 646-649-9930

* The 2010 Leadership Award Recipient will be notified in January. The nominator and awardee will be honored guests at the 2010 ACOG ACM Kenneth J. Ryan, MD, Memorial Program; Award Ceremony and Luncheon.

Please see application form below.

Application Form: 2010 Kenneth J. Ryan, M.D. Physician Leadership Award
Date:       Nominator General Information:
Full Name:       Last Title:       Specialty:       Contact Information:       Street address       City       Email       Apt/Suite       State       Phone       First       M.I.

      ZIP Code

Nominee General Information:
Full Name:       Last Title:       Specialty:             Work Contact Information: Department       Street Address       City       Email       First       M.I.

     

Apt/Suite       State       Phone       ZIP Code

Nominee’s CV: (cut & paste)
Insert CV here by cutting and pasting from a word document, or you may send the CV as an email attachment to penny@prch.org with the application.

500 word Description of Nominee: (follow directions below)
Below, please describe in 500 words or less the nominee and her/his longstanding work to improve reproductive health in; (1) research, (2) education, (3) clinical service, and (4) advocacy over the course of their career. Descriptions should include specific examples of the nominee’s particularly successful work in all four areas and the resulting substantial improvements to reproductive health.

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