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Junior Doctor Awards

Junior Doctors Awards 2019 Educational or Clinical Supervisor Nomination Form

Educational or Clinical Supervisor

This prestigious award is presented to an exceptional individual who throughout their career have freely given their time and willingly shared their skills and knowledge to support, train and empower the next generation of doctors.

Nomination details:

About your nominee

Nominees full name*

Nominees department*

Nominees main work site*

Nominees email address

Your nomination:

In no more than 350 words, please write your nomination here

Nomination*

About you

Your full name*

Your job title*

Department you work in*

Your base site

Your email address*

Consent of nomination

Nominations are automatically published both in internal publications and on social media, this would include the nominees details, your name and a synopsis of your nomination.

I give my consent as indicates above*

From time to time, we may come across external awards which we feel your nomination is suitable for. Generally, these awards require a little more information than what you have provided above. we will contact you with the external award details and ask that you consider submitting a nomination in one of the categories.

I give my consent to the above*

And finally

Please check that you have completed all of the required fields then click on submit

Email 2*:

* required fields

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