Nominee's Name (required)

CFPC Membership #

Years of joining CFPC

Year of Certification

Year of Fellowship (if applicable

Practice Profile

Activities in Medical Organizations

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Education Profile (university and postgraduate)

Is the nominee aware of this nomination? (required)

YesNo

Nominator's Name (required)

CFPC Membership # (if applicable)

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Nomination Letter
Each year, the Saskatchewan College of Family Physicians confers this award upon a member deemed to exemplify the ideals of family medicine. The award is adjudicated on the basis of the individual’s contribution through medicine generally, family medicine in particular, community through government, social, church or other activities as well as participation in the College of Family Physicians of Canada or the Saskatchewan College.

To qualify for nomination, a physician must have been in family practice for at least 15 years and a MEMBER of the College of Family Physicians of Canada for at least 10 years.

The recipient will be the Saskatchewan Chapter’s nominee for the Reg. L. Perkin, Canadian Family Physician of the Year Award as one of the ten Family Physicians honoured by the CFPC in 2016.

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Nominee's Name (required)

CFPC Membership # (if applicable)

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Is the nominee aware of this nomination? (required)

YesNo

Nominator's Name (required)

CFPC Membership # (if applicable)

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Nomination Letter
The Awards of Excellence recognize CFPC members who in the past 12-24 months have made an outstanding contribution in a specific area pertaining to one or more of the following areas: patient care, community service; hospital or health care institutions; College activities (National or Chapter); teaching research or other elements of the academic discipline of family medicine.

Examples Include:

• Charitable or humanitarian work

• Outstanding teaching

• Excellence in clinical practice

• Innovative research program

• Leadership during community outbreak of infectious disease

• Establishment of training program in family violence

• Innovations in developing a new program to address a health care need

• Leadership role in a hospital or regional health care program

Recipients of the Awards of Excellence will be recognized by their Chapters at the Annual Scientific Assembly/Annual General Meeting and/or other Chapter events.

The recipients will also be recognized during Family Medicine Forum.

Nomination Process:

Nominations are invited from CFPC members and the public and must be submitted to the Chapter office of the nominee.

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Nominee's Name (required)

CFPC Membership # (if applicable)

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Is the nominee aware of this nomination? (required)

YesNo

Nominator's Name (required)

CFPC Membership # (if applicable)

Address (required)

City (required)

Province (required)

Postal Code (required)

Phone Number (required)

Email (required)

Nomination Letter
This award is intended to recognize an individual, group or organization that has made a significant contribution to family medicine in Saskatchewan. This contribution may have occurred through clinical, research, educational, or administrative activities. The award is open to college members and non-members. It will recognize contribution made within the province or nationally.

Nominations will be accepted from Saskatchewan College of Family Physicians members. The recipient will then be selected by the Awards Committee.

The recipient will be recognized at the Chapter’s Annual Banquet held in conjunction with the Annual Scientific Assembly. The award will consist of complimentary banquet tickets for the individual and guest or designated recipient accepting the award.

Nomination Process:
Nominations are invited from CFPC members and the public and must be submitted to the Chapter office of the nominee. Nominations should include a brief introduction to the nominee, and why they are being nominated.

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Nominee:

Nominee's Name (required)

Clinic Name #

City/Town

Nomination made by:

Name (required)

City/Town

Phone Number (required)

Email (required)

How did you hear about this award?

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What makes your Family Doctor rock?

If my family doctor receives this award, I give my permission for the Saskatchewan College of Family Physicians to use my name along with some of the information from this nomination, to recognize my doctor’s work.
YesNo

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