UTMB Dept. Pediatrics
Pediatric Education Awards
Pediatric Community Preceptor Award
Nomination Form
Directions:
Complete this form. Save and notice where you saved it.
Upload as an e-mail attachment to Virginia Niebuhr vniebuhr@utmb.edu
We request you make every effort to keep this nomination secret from the nominee.
Pediatric Community Preceptor Award - for a community preceptor who teaches students or residents
Qualifications:

The awardee must have given at least two years of service to the Department of Pediatrics’ educational mission.

Previous awardees may be considered but not in consecutive years and only if new contributions have been made since
the time of the previous award.
Previous awardees: www.utmb.edu/pedi_ed/AWARDS/awardees.htm
Nominee:
Nominee’s Address:
Nominee’s Phone:
Nominee’s Email:
Length of service to the Department of Pediatrics’ educational mission, in years:
Involvement in medical education
Practice of Medicine One- MS1
Practice of Medicine Three – MS3
Texas Pediatric Society Preceptorship
Pediatric Clerkship – MS3
Pediatric Ambulatory Community Selective
Health & Development Curriculum - PGY1
Residency Elective
Other:
Comments about this nominee: (expandable box)
Nominators (s)
How to contact you
Date
The Departmental Office of Medical
Education will make every effort to
provide the selection committee with
any available learner evaluations of
this nominee.