Paul Ambrose Award Nomination Form

*Asterisk indicates required field. (All fields are required.)

*Name of Nominee:

*Program Year of Nominee:
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*Specialty of Nominee:
Select One Allergy & Immunology Anesthesiology Cardiology Dermatology Emergency Medicine Family Practice Internal Medicine Medical Genetics Neurological Surgery Neurology Nuclear Medicine Obstetrics & Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine & Rehabilitation Pathology Plastic Surgery Preventative Medicine Psychiatry Radiation Oncology Radiology - Diagnostic Surgery - General Thoracic Surgery Urology Other Prefer not to respond

*Address of Nominee:

*City:

State:
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*ZIP Code:

*Nominee Phone:

*Nominee E-mail:

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*Name/Contact of Person Completing Form:

Eligibility: Nominees and the award recipient must be members of the American Medical Association. Any individual or organization may nominate more than one individual. Nominees should plan to attend the American Medical Association Annual Meeting in Chicago, Illinois. The award will be presented at the AMA-RFS Annual Meeting in June 2008.

Required Documentation: All nominations must also include a copy of the nominee’s current curriculum vitae and a typed essay of 500 words or less describing the candidate’s excellence and leadership in public health. If you are completing this form online, please e-mail the candidate's curriculum vitae to rfs@ama-assn.org or fax (312) 464-5845. All materials should be submitted and e-mailed no later than Feb. 29, 2008.

Essay: In 500 words or less, describe the nominee’s involvement with public health activities and leadership. Public health involvement may include any activities involving education, awareness, advocacy, and/or community service in public health projects. Each nomination must comment specifically on these three areas:

• Positive effect of resident physician’s efforts on a given community, training institution, or population in the arena of public health;
• Resident physician’s level of involvement and leadership demonstrated in the arena of public health;
• Extent and thoroughness of resident physician’s project planning, implementation, and outcomes in the arena of public health.