Alumni Award Nomination Form

The Wisconsin Medical Alumni Association (WMAA) invites alumni to nominate their fellow alumni and, in some cases, faculty and staff of the UW School of Medicine and Public Health or UW Health, to be considered for WMAA awards. Previous winners will not be considered.

"*" indicates required fields

Nominator Information

Full Name*

First Middle Last Suffix

Email*

I'm nominating this candidate for the:

The Medical Alumni Citation – Distinguished Alumni Award honors a medical school alumnus who has achieved distinction in medicine. Achievement is recognized through excellence in the practice of medicine, in academic activities and in research accomplishment. The award will be made at the annual WMAA Awards Banquet only to individuals who are able to personally attend the ceremony.

The Resident/Fellow Citation – Distinguished Resident Award honors an individual who has completed a residency or fellowship at the University of Wisconsin Hospital and Clinics and has achieved distinction in medicine. Achievement is recognized through excellence in the practice of medicine, in academic activities and in research accomplishment. The award will be made at the annual WMAA Awards Banquet only to individuals who are able to personally attend the ceremony.

The Early Career Achievement Award honors a UW School of Medicine and Public Health MD alumna/alumnus who has attained exemplary success early in their career. They will have made outstanding contributions through clinical service, research, education and/or administrative leadership. An alumnus/a may receive the award no longer than 20 years following their graduation year from UW SMPH.

The Emeritus Faculty Award recognizes outstanding service to the UW School of Medicine and Public Health. It is awarded to an emeritus faculty in the Basic and Clinical Sciences who has exhibited exceptional commitment to the school over a period of years.

The Ralph Hawley Distinguished Community Service Award is conferred on a UW School of Medicine and Public Health MD graduate who has made outstanding contributions to his/her local community through medical practice, teaching, research, or humanitarian activities.

The Medical Alumni Service Award honors a UW School of Medicine and Public Health MD graduate who has made an exceptional commitment to the Wisconsin Medical Alumni Association over a period of years.

The Honorary Life Membership Award honors an individual who has been particularly supportive of and helpful to students and alumni. This award is given to a non-alumnus, typically a staff member in the SMPH or the WFAA.

Nominees will be considered for 5 years post nomination date. After 5 years, resubmission is required for future consideration.

Type of Science for Emeritus Award*

Basic Sciences

Clinical Sciences

Letter of Nomination (as PDF)*

Accepted file types: pdf, Max. file size: 2 MB.

Candidate Information

Full Name*

First Middle Last Suffix

CV/Resume (as PDF)*

Accepted file types: pdf, Max. file size: 2 MB.

Current Position/Title*

Former Position/Title

UW Hospitals and Clinics GME Position(s)

Residency

Fellowship

Year of Residency Graduation

Year of Fellowship Graduation

Specialty

Year MD Completed*

YYYY

Year MD Completed (if applicable)

YYYY

Summary of Distinctions Achieved in Medicine*

Explain why this candidate is qualified

Summary of Accomplishments*

In areas of teaching and/or research or noteworthy administration, including program development

Special Achievements by Candidate in 3 Categories of Accomplishments Being Reviewed by the WMAA

Practice of Medicine*

Academic Activities Such as Teaching*

Research Contributions*

Contributions to Local Community*

Contributions to UW School of Medicine and Public Health Students and WMAA*

Contributions to WMAA*

Other Qualifications (optional)

This may include descriptions of leadership roles, national awards, recognitions, and honors

This field is for validation purposes and should be left unchanged.