George E. Thibault, MD Nexus Award Nomination Form

Main contact first name:

Main contact last name:

Email address for main contact:

Telephone:

Initiative/practice site name:

Check one awardee caregory:

Single-System Implementation

Multi-System Implementation

Occupations represented on the team:

Name of representative who will attend and present at Nexus Summit (if different from main contact listed above)

Application (maximum of five pages, single spaced, 1-inch margins and 12-point font) must include the following:

Purpose statement for the initiative or practice model
Brief history (including inception date) of the initiative, practice model, and identification of key stakeholders within the initiative
Description of the initiative or practice model to include
- How the initiative or practice model functions
- How the key elements listed under Criteria are reflected
- Evidence of impact
Clear articulation of how the initiative demonstrates leadership and innovation in the integration of collaborative practice and interprofessional education, in academic and practice partnership(s) at the specified award level.

Application (3 pages max, PDF format):

Supporting material such as pictures, news or magazine clippings may be submitted as a single pdf with your application (5 pages max):