2022 Imaging Professional for Excellence Nomination

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* 1. Nominator's Name

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* 2. Nominator's Phone Number

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* 3. Nominator's Email Address

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* 4. Nominee Name

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* 5. Nominee Phone Number

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* 6. Nominee Email Address

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* 7. Job Title and Name of Employer

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* 8. Credentials

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* 9. What is the highest level of school they have completed or the highest degree they have received?

Associate Degree

Bachelor Degree

Master Degree

Doctorate

Other (please specify)

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* 10. How many years of experience does the nominee have as a registered medical imaging or radiation therapy professional?

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* 11. Please select from the choices below any professional involvement the nominee has engaged in.

Professional Society Memberships

Served on a committee within NCSRT or other Medical Imaging Society or comparable

Held an office for NCSRT or other Medical Imaging Society or comparable

Other (please specify) - please feel free to use this to elaborate on selections above if you like.

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* 12. Please describe work related professional involvement.

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* 13. Please describe how the nominee positively promotes and advances the Medical Imaging and Radiation Therapy profession in their practice setting and/or in the community.

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* 14. Please describe the nominee's character and how they demonstrate integrity, honesty, and function within their scope of practice.

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* 15. How does the nominee display commitment to patients, families and their colleagues?

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* 16. Describe how the nominee interacts with others to assist in their professional growth.

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* 17. Do you consider your nominee to radiate energy and truly make a difference to overall outcomes in your practice setting? If yes, please explain "why".

Yes

If yes - please make sure you describe how.

2022 Imaging Professional for Excellence Nomination

Question Title

* 1. Nominator's Name

Question Title

* 2. Nominator's Phone Number

Question Title

* 3. Nominator's Email Address

Question Title

* 4. Nominee Name

Question Title

* 5. Nominee Phone Number

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* 6. Nominee Email Address

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* 7. Job Title and Name of Employer

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* 8. Credentials

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* 9. What is the highest level of school they have completed or the highest degree they have received?

Question Title

* 10. How many years of experience does the nominee have as a registered medical imaging or radiation therapy professional?

Question Title

* 11. Please select from the choices below any professional involvement the nominee has engaged in.

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* 12. Please describe work related professional involvement.

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* 13. Please describe how the nominee positively promotes and advances the Medical Imaging and Radiation Therapy profession in their practice setting and/or in the community.

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* 14. Please describe the nominee's character and how they demonstrate integrity, honesty, and function within their scope of practice.

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* 15. How does the nominee display commitment to patients, families and their colleagues?

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* 16. Describe how the nominee interacts with others to assist in their professional growth.

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* 17. Do you consider your nominee to radiate energy and truly make a difference to overall outcomes in your practice setting? If yes, please explain "why".

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* 18. In one sentence - please describe what makes this person an outstanding Imaging Professional.