6th Annual MTSA Mission & Awards Gala

Award Nomination Form

Thank you for participating in MTSA's Mission & Awards Gala nomination process. Below are the criteria for the five awards.

You may submit nominees for as few or as many of the five awards as you wish. However, if you would like to nominate more than one person for the same award, you must complete this survey first, then start a a new survey for each subsequent nominee in the same category. Please include as much contact information for the nominee as possible.

AWARD CRITERIA

Ikey DeVasher Distinguished Alumni Service Award is awarded to a Middle Tennessee School of Anesthesia Alumnus annually in honor of this MTSA Alumnus and former Dean/Vice President/Program Administrator to celebrate and honor her 45 years of dedicated work and distinguished service.

Nevin Downs, MD Leadership Award is awarded to an Anesthesia Provider (Anesthesiologist or Certified Registered Nurse Anesthetist) who personifies the integrity, honesty, fairness, and exemplary leadership with which Dr. Downs served the profession, including his advocacy of Nurse Anesthesia and MTSA.

Clinical Excellence Award is to be awarded to an Anesthesia Provider (Anesthesiologist or Certified Registered Nurse Anesthetist) or Clinical Site (Hospital, Clinic, etc.) that provides a nurturing and exemplary atmosphere with true eagerness to instruct, train, and educate MTSA students. The recipient will embrace the MTSA mission and core values.

Philanthropy Award is to be awarded to an outstanding major benefactor to Middle Tennessee School of Anesthesia. The recipient may be an individual, corporation, foundation, or family.

Mission & Heritage Award is awarded to an individual who embodies and exemplifies the Heritage, Mission, and Core Values of MTSA.

Question Title

* 1. Ikey DeVasher Distinguished Alumni Service Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 3. Nevin Downs, MD Leadership Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 4. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 5. Clinical Excellence Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 6. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 7. Philanthropy Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 8. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 9. Mission & Heritage Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 10. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 11. Philanthropy Award Nominee

Nominee Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 12. Why are you nominating this person? (How does the nominee meet the award criteria?)

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* 13. Your Information (person submitting the nomination)

Your Name *

Company:

Address: *

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *