AAPA PAragon Awards Application Form

Don't forget the deadline for receipt of completed applications for all AAPA PAragon Awards is JANUARY 15. For more information call 703/836-2272, ext. 3513, or send an e-mail to awards@aapa.org.

For help with filling out this form, please read the Award Nomination Tips page on the AAPA Web site. For more information about the awards and the awards process, call 703/836-2272, ext. 3513, or send an e-mail to awards@aapa.org.

Please select from the following:

I am filling out the application form with the candidate's permission.

My Name:

My E-mail Address:

I am the candidate nominated for a PAragon Award and am filling out the form myself.

CANDIDATE INFORMATION

* indicates response required

*Candidate's Name:

*Address:

*City/State/Zip:

*Phone:

E-mail Address:

AAPA Member ID# (if known):

This is an application for the following PAragon Award:

Outstanding PA of the Year

PA Service to the Underserved Award

Humanitarian PA of the Year

Physician-PA PArtnership Award (special additional section to be filled out below for this award)

If this is an application for the Federal Service PA of the Year Award, do not use this form. Please speak with a representative of one of AAPA's recognized federal service constituent organizations — Naval Association of PAs, Society of Air Force PAs, Society of Army PAs, Public Health Service Academy of PAs, Veterans Affairs Physician Assistant Association, or Veterans Caucus. Nominations are made by the boards of directors of the federal service constituent organizations using the Federal Service PA of the Year PAragon Award form.

Individuals interested in applying for the PAragon Publishing Awards must use the Publishing Awards Application Form. Do not use this application form for a Publishing Award.

1. What year did you join AAPA?

2. How long have you been a PA?

If you have an electronic copy of a current curriculum vitae (CV) or résumé, please attach your file here. If not, please complete questions 3-6 immediately below.

File:

3. Employment to date

4. Educational background (degrees, honors, scholarships, etc.)

5. Health care related and other leaderhsip positions

6. Memberships in other organizations. Include awards, commendations, and offices held.

COMMITMENT TO PATIENTS

7. Describe your professional achievements that demonstrate the PA profession’s philosophy of providing quality, cost-effective, and accessible health care. Include all activities of local, national, or international significance that relate to this philosophy.

8. Describe your volunteer achievements that are of local, national, or international significance that relate to the award for which you are applying.

9. Describe any difficulties you’ve encountered providing care in your practice setting.

10. Provide evidence of your commitment to protecting human rights. (Write N/A if not applicable to the award.)

11. How have your activities increased accessibility to health care in a national or international practice setting? (Write N/A if not applicable.)

FOR PHYSICIAN-PA TEAM AWARD NOMINEES ONLY

Please answer questions 12-17 immediately below. Nominees for all other PAragon Awards, please skip to the section on Letters of Recommendation below.

12. Physician's name:

13. How many years have you worked together as a team?

14. Is the physician a member of a national physician’s organization? If so, which one?

15. Describe how you work effectively as a team to provide care.

16. Describe how patients are educated about your team’s approach to providing quality care.

17. Describe how your team has served your community and the medical profession.

LETTERS OF RECOMMENDATION

ALL nominees must provide two (2) letters of recommendation related to service on behalf of the PA profession. A statement of nomination can be used as one of the letters of recommendation. The letters may be sent separately but must arrive by the January 15 deadline. Letters should be sent to AAPA PAragon Awards, 950 N. Washington Street, Alexandria, VA 22314-1552. Or they can be faxed to 703/684-1924 or sent by e-mail to awards@aapa.org.

Please indicate below who will be sending the letters of recommendation.

The receipt deadline for all completed applications is January 15. Selections are made in February, and all applicants are notified before the end of March. If you have any questions about the awards or the awards process, please contact AAPA staff at awards@aapa.org; 703/836-2272, ext. 3513.

How did you learn about the PAragon Awards program? Select one.

Thank you for taking part in AAPA’s PAragon Awards program.