Ron L. Nelson Award of Achievement Nomination Form

ELIGIBILITY

Nominee does not have to be a PA or MAPA member.

CRITERIA

The Nominating Committee will consider the following criteria when reviewing applications:

Is the nominee well recognized by members of the PA profession and others?
Has the nominee demonstrated a commitment to furthering the PA profession in Michigan?
Has the nominee advocated for the PA profession?
Has the nominee served or improved service to patients and the community?

EXAMPLES OF EVIDENCE TO SUPPORT A NOMINEE

#1 Evidence of recognition by all segments of the PA profession and by others:

Is this person well known by the PA profession and well recognized by PAs of different generations?
Is this someone for whom there is 'clear evidence' of his/her commitment to the PA profession?
What awards and forms of recognition has this person received during his/her career?

#2 Evidence of commitment to the PA profession:

How has this person demonstrated long-tem commitment to the PA profession?
Has this person spent time outside of clinical practice to promote the PA profession?

#3 Evidence of time spent educating and influencing others in support of the PA profession:

Has this person lobbied for the PA profession? (In this context, 'lobby' could mean either (or both) legislatively or before individuals and groups that can impact the PA profession.)
How has this person taken the PA message to physician organizations, to others within his/her own profession or organization, and to those within his/her sphere of influcence?
You may also email letters of recommendation, news articles and other relevant supporting material to MAPA@MichgianPA.org.

Nominator Infomation

Please provide your contact information.

Nominator's First Name

Nominator's Last Name

Nominator's Email

Nominator's Primary Phone

Does the nominee know you are nominating him/her?

How do you know the nominee?

Nominee Information

Please provide contact information for the nominee.

Nominee's First Name

Nominee's Last Name

Nominee's Email

Nominee's Primary Phone

How long as the nominee been associated with the PA profession?

In what capacity?

Award Criteria

Please provide specific information about the nominee's accomplishments and character.

What 3 words best describe your nominee's outstanding personal qualities?

In one sentence, summarize the nominee's overall accomplishments or achievements.

What distinguishes this person in the PA profession in the State of Michigan? Provide evidence and support as to why the nominee is deserving of the award. (Max 500 words.)

Send me a copy of my responses

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