TOY

Family Medicine Teacher of the Year Nomination Form

About you
Your Name *
Email Address *
Phone number
About your nominee for Teacher of the Year
Name *
Institution *
City *
Teaching role *

Employed educator Volunteer faculty/preceptor
Important details
How long have you known this doctor?
This family doctor teaches (check all that apply) *

Me Medical Students Residents Other clinicians (NPs, PAs, RNs) Praciticing family physicians
Do you work with your nominee? *
Other connection to nominee, if not a colleague
Please tell us more about your nominee. This will serve in place of a support letter.
How does this doctor provide outstanding education?
Describe an innoviative activity that this nominee uses or created at your institution
How does this doctor serve as a role model for current and/or future family physicians?
Please add a few comments about the doctor's special attributes that you feel should be considered.
You can attach any supporting documents/articles/photos here. This is optional, not required.
In checking this box I give consent for IAFP staff to contact me about my nomination. *

I agree
Should be Empty: