American College of Emergency Physicians National Emergency Medicine Medical Student Award Nomination Form. Due Date: February 14, 2012

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1 Nomination Form Due Date: February 14, 2012 Please follow instructions closely, and make sure you have included all requested information listed on the checklist. Electronic submissions only. Please refrain from sending extraneous information.

2 Application Packet Please read these instructions carefully. Applications that do not follow these instructions with regard to format and supporting documentation cannot be accepted. If the application deadline has not passed, the application may be resubmitted after deficiencies are addressed. Extension of the deadline will not be granted to allow resubmission in the award cycle. Also included for your reference are forms used by the reviewers to score and evaluate an application. The procedures for review are outlined below: 1. Reviews by ACEP staff to ensure all submission instructions have been followed. 2. Initial review of successful applications by the Academic Affairs Committee Chair and Academic Affairs Medical Student Awards Subcommittee Chair to ensure eligibility, suitability, and general competitiveness for this category of award. 3. Successful reviewed applications by the Academic Affairs Medical Student Awards Subcommittee are recommended for an award. 4. Successful applications will be submitted to the ACEP Board of Directors for a final decision. 2 Revised: 3/15/08

3 General Information Deadlines Deadline for receipt of application: February 14, 2012 Notification of award: April 30, 2012 Mail electronic file of application to: ACEP National Medical Student Award American College of Emergency Physicians 1125 Executive Circle Irving, TX Introduction The American College of Emergency Physicians sponsors a national medical student award to honor outstanding students in emergency medicine who have demonstrated excellence the values important to ACEP. The award is designed for students who recognize and promote emergency medicine as an essential public service. The student should show commitment to high quality patient care, teaching, leadership, research, and innovation. The award will recognize students that have shown evidence of a high level of humanism, professionalism, and clinical judgment. Students should be involved with community service and research that supports the values of emergency medicine. Students should show commitment to service in medical organizations. While the documentation required for this award is extensive, the process is designed to mimic the procedure used by university promotion and tenure committees in their tenure deliberations. Recipients of this award will receive national recognition that can be used to document their excellence in humanism and professionalism in medicine. Scope The College will recognize up to 10 award winners annually. Recognition Award winners will be recognized during the ACEP Awards Ceremony at the Scientific Assembly meeting. Award winners will be recognized by the publication of their names in ACEP News or other College publications. 3 Revised: 3/15/08

4 ACEP Academic Affairs Committee has urged recognition of the award winners at their respective medical school graduations. We encourage nominators and departmental directors to suggest that medical school deans include this award in graduation exercises. Eligibility To be eligible for the award, the student must: 1. Be a member in good standing of a US allopathic or osteopathic medical school. 2. Applying for a position in Emergency Medicine within the National Resident Matching Program (NRMP) match. Process and Limitations 1. Students must be nominated by the EM academic chair, Residency Program Director(Assoc/Assist), Division Head, or clerkship director, and submit a complete official application form. Include a CV as part of the application form as a separate attachment. 2. Nominations are reviewed by a subcommittee of the Academic Affairs Committee. Subcommittee recommendations are presented to the ACEP Board of Directors for approval. Criteria The Academic Affairs Committee will evaluate applications in each of the following categories: 1. Letter of endorsement by the program s academic chair, program director, or head of emergency medicine declaring the department s support for the nomination. 2. Humanism, professionalism, leadership, and clinical judgment as attested to by the nominating individual. 3. Leadership and service to medical organizations (e.g. AMSA, EMRA, ACEP, EMIG) 4. Community service (e.g. local clinics, missions, etc.) 5. Research and publications 6. Academic excellence Nominees are scored in each category and numerical results tabulated. Prior to submission of their recommendations to the ACEP Board of Directors, the entire subcommittee reviews final tabulations and all relevant data on each applicant. 4 Revised: 3/15/08

5 Application Instructions The application must be received on no later than the deadline date indicated under general information. Electronic files should be in PDF or MS Word format. All applications must be in English and free of jargon and unusual abbreviations. For terms not universally known, spell out the term the first time it is used with the appropriate abbreviation in parentheses; the abbreviation may be used thereafter. Type the application, single-space; type size should be 12-point font with headings no larger than 14 point (this applies only to Word documents and not PDF). While submission of a CV is required, the CV will not be considered a sufficient response to sections 4-7. Incomplete or late applications will not be considered. The application consists of seven sections and should be placed in this order: 1. Title Page Provide all information requested (template on page 8). Note that the academic chair, program director, or clerkship director must sign the title page. The electronic file must include signatures. 2. Endorsement by the Academic Chair, Program Director, Division Head, or Head of Emergency Medicine The applicant must include a letter from the academic chair, program director, or clerkship director outlining their assessment of the applicant s humanism, professionalism, leadership, and scholarly achievement. Providing examples or supporting information constitute the strongest endorsement. The program director, academic chair or clerkship director is responsible for the verification of the application material by signifying they have reviewed and verified the authenticity of the packet materials, especially with regard to authenticity of leadership and service to medical organizations, community service, and research and publications. This letter should acknowledge the department s support for the nomination. 3. Endorsement by the Nominator The applicant must include a letter written by the nominator entailing the humanism, professionalism, leadership, and clinical judgment of the applicant; examples constitute the strongest endorsement. This may include input from the program's residents, the student's peers, or pertinent comments from other faculty. 4. Documentation of leadership and service to medical organizations The applicant should summarize any leadership positions held within and service to medical organizations (e.g. AMSA, EMRA, ACEP, local EMIG, University or SOM). Include extent and duration of service or leadership position held. 5 Revised: 3/15/08

6 5. Documentation of community service Applicant should list and briefly describe any type of community service that applicant was involved in during medical school (e.g tutoring, underserved clinics). Include extent and duration of involvement, leadership positions held, and any innovations or improvements directed. 6. Documentation of Research and Publications The applicant should provide detailed information about any and all research activities related to medicine to include abstracts accepted, oral or poster presentations, and publications. Publications may include editorial letters, case reports, research, book chapters, and educational articles. All current and past research activities during medical school should be listed with attention given to the applicant s level of participation. 7. Awards The applicant should provide detailed information about any awards received during medical school to include AOA membership. 8. Academic Excellence Grades during medical school, performance on USMLE step 1 and 2, as well as class rank should be supplied. Include the applicant s MSPE or Dean s letter submitted with the ERAS application. 6 Revised: 3/15/08

7 Application Checklist Before submitting your application, please use this checklist to ensure you have complied with all application requirements. Nominee meets eligibility requirements on page 4 Application includes all seven sections in the order given on pages 5 and 6 Application includes signed title page (template on page 8) Title page includes electronic signatures Application is being submitted via as electronic files in PDF or MS Word format Application is being submitted by the deadline 7 Revised: 3/15/08

8 Title Page Name of Nominee: Business Address: Telephone Number: Fax Number: Address: Name of Individual completing this application (include title): Address: Is nominee aware of nomination? Yes No Academic Chair Program Director Clerkship Director Date Date Date 8 Revised: 3/15/08