Basic InformationName* First Last Degree(s) Your title:* Your Institution:* Your email address:* Name of nominee:*Nominee's Institution:* Nominee's title:* Nominee's email address:* EligibilityIs the nominee a senior resident (PGY4 or higher)?* Yes No Is the nominee a fellow who has completed residency?* Yes No Is the nominee early-career faculty (within first 5 years of independent practice?* 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 passion and enthusiasm for surgical education scholarship?*Please give an example of the nominee role modeling professionalism.*Additional InformationPlease list program or curriculum development or scholarly projects the nominee has led.*Please list the nominee's peer-reviewed manuscripts related to surgical education.*Please list the nominee’s leadership roles in courses or groups related to surgery and surgical education, including involvement in national committees related to surgical education as well as local leadership roles.*Please list the nominee’s educational awards and honors.*File Uploads:Please upload nominee's CV*Accepted file types: pdf, Max. file size: 512 MB.Please upload an educational scholarship statement that includes a synthesis of contributions to educational scholarship and vision for the nominee's educational scholarship over the next 3-5 years.*Accepted file types: pdf, Max. file size: 512 MB.EmailThis field is for validation purposes and should be left unchanged.
