Basic InformationYour name:* First Last 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 Suffix Nominee's Institution* Nominee's title* Nominee's email* Please confirm nominee's email* 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 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.*HiddenCV:*Max. file size: 512 MB.HiddenLetter of Support from Clerkship Director (or equivalent)*Max. file size: 512 MB.HiddenLetter of Support from Medical Student*Max. file size: 512 MB.HiddenLetter of Support:*This additional letter of support may be from another medical student or administrative staff. Max. file size: 512 MB.NameThis field is for validation purposes and should be left unchanged.
