Psom

2014 CR CARE Awards Nomination


Nomination Period Closed

Please note that you must fill out all the fields in this form in order to submit the nomination.
Use NA if a question is not applicable.

Nominee Information

Name:

  
 First
   Last

Job Title:

Department/
Division/ Center:

Penn Mailing Address:


Contact Information:

Voice:

Email:

Number of years at Penn:    Number of years in department:  
Number of years in CRC
Role/Position:                     
Number of direct reports
if applicable):                              
Number of studies:             

Complexity of studies:     

Within Penn
 External to Penn
IRB Member
Lecturer/ Presenter
Professional Organizations
Community Affiliations
Awards of Distinction
Certifications
Publications/ Manuscripts
Other

As the nominator, select an award and provide examples of the nominees qualifications for the award. Please consider using the guidance document for demonstration of additional qualifications.

Select Award:

Rising Star Award:

Leading Edge in Clinical Research Award:

Lifetime Achievement Award:

Nominator Information

Name:

  
 First
   Last

Job Title:

Department/
Division/ Center:

Penn Mailing Address:

Contact Information:

Voice:

Email:

Relationship to Nominee:

Letters of Support

Two letters of support are required in addition to the nominators submission.
Please provide the contact information of the two individuals who will be providing letters of support. OCR will contact them directly in order to obtain the official letter.

Support Contact Information:

Letter 1 (Required)

 Name
 Phone
   Email

Letter 2 (Required)
 Name
 Phone
   Email