"*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Basic InformationYour name:* First Last Your degree(s): Degree(s) Your title:*Your institution:*Your email address:* Nominee InformationPlease enter the information of the person you are nominating below. Name of nominee:* First Last Nominee's degree(s):Nominee's institution:*Nominee's title:*Nominee's email address:* Please confirm nominee's email address:* EligibilityHas the nominee been an active member of the ASE for more than 1 year?*Please contact membership@surgicaleducation.com to confirm member status. Yes No Has the nominee been in the role of clerkship coordinator for more than 3 years?* Yes No Has the nominee demonstrated improved processes and or communication between medical school and department of surgery?* Yes No Has the nominee won the ASE Clerkship Coordinator Recognition Award before?* Yes No Has the nominee presented material related to surgical clerkships at local/national meetings?* Yes No The nominee is not eligible for the award at this time.Short EssaysPlease write about one paragraph on each of the following:Why do you think the nominee deserves this award?*How has the nominee demonstrated creativity, expertise, and commitment to their work within the surgery clerkship program?*How has the nominee demonstrated passion for supporting medical student education and for contributing to the continuous improvement of the educational experience for medical students in surgery?*How has the nominee demonstrated commitment to the education of peers through presentations or other active roles within their institution and the Association for Surgical Education (ASE)?*How has the nominee demonstrated effective communication and approachability?*Please give an example of how the nominee has demonstrated an enthusiastic attitude towards medical students and the surgery clerkship program.*Please give an example of when the nominee has role modeled professional behavior.*Additional InformationPlease list the nominee’s leadership roles inside and outside their institution, including professional organizations related to medical student education.*This field is hidden when viewing the formCV:*Max. file size: 512 MB. This field is hidden when viewing the formLetter of Support from Clerkship Director (or equivalent)*Max. file size: 512 MB. This field is hidden when viewing the formLetter of Support from Medical Student*Max. file size: 512 MB. This field is hidden when viewing the formLetter of Support:*This additional letter of support may be from another medical student or administrative staff. Max. file size: 512 MB.
