The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

ZnSaL4UyVzLdKJ2bDdi4iQAmHUPoQxqvVY2resVHwI7gn46XkGfqh8CAy9QbUgKzisTRaJn5Hc

2022 CARE Awards Nominations Form

Returning?

A A A

Thank you for taking the time to complete this nomination form.

Nomination Guidance: http://www.med.upenn.edu/ocrobjects/society/CR_CARE_Award_Characteristics.pdf

For a full description of the event: https://www.med.upenn.edu/scrcm/careawards2022.html

You must fill out all of the fields in this form in order to submit a nomination for the 2022 C.A.R.E Awards for Clinical Research Coordinators. Before starting survey, please review the survey to have all information available.

IMPORTANT NOTE FOR NOMINATORS: This form is reviewed by the Award Selection Committee. Provide nominees characterisitcs and attributes in as much detail as possible.

Nomination period will end on Friday August 15th, 2022 7PM. Deadline is for the NOMINATION only. Letters of support are NOT required to submit this nomination form.

First Name

* must provide value

Last Name

* must provide value

Job Title

* must provide value

Department/Division/Center

* must provide value

Office Phone Number

* must provide value

The next few questions are about the nominees background in clinical research. Please fill this out to the best of your ability. Ask the nominee for this information, if you don't have this available.

Email (Nominee's UPenn email)

* must provide value

Number of years at Penn:

* must provide value

Number of years in department:

* must provide value

Number of years in CRC role/position:

* must provide value

Number of direct reports (Indicate 0 if not applicable, do not leave blank):

Number of studies:

* must provide value

Complexity of Studies

Provide the committee with a brief idea on types of studies the nominee works on eg: first in human, several phase 4s, large enrollment goals, vulnerable patient population, multi site, investigator initiated studies etc.

* must provide value

Expand

Indicate if an individual has served in the following roles or qualifies as a part of any category. Also provide further details if a box is marked.

Within Penn

External to Penn

Not Applicable

IRB Member

* must provide value

Lecturer/ Presenter

* must provide value

Professional Organizations (e.g: ACRP, SoCRA)

* must provide value

Community Affiliations

* must provide value

Awards of Distinction

* must provide value

Certifications (eg. ACRP, SoCRA, Penn CRC)

* must provide value

Publications/ Manuscripts

* must provide value

IRB Member (Please list the name/s of review boards they served on)

Expand

Lecturer/ Presenter (Describe role)

Expand

Professional Organizations Description (Please list)

Expand

Community Affiliations (Please list)

Expand

Awards of Distinction (Please list)

Expand

Certifications (Please list)

Expand

Publication/ Manuscripts (Provide abbreviated list or links)

Expand

As the nominator, select an award category that best describes the nominee. Please consider using the guidance document link at the very top of this form, in making your selection.

Select Award

Rising Star Leading Edge Lifetime Achievement

reset

Rising Star Award

Describe briefly the nominee's merits for this award. Use the guidance document in the link above, if needed.

If the nominee was involved in the conduct of COVID19 clinical trials, please mention specific examples

Expand

Leading Edge in Clinical Research Award

Describe briefly the nominee's merits for this award. Use the guidance document if needed.

If the nominee was involved in the conduct of COVID19 clinical trials, please mention specific examples

Expand

Lifetime Achievement

Describe briefly the nominee's merits for this award. Use the guidance document if needed.

If the nominee was involved in the conduct of COVID19 clinical trials, please mention specific examples

Expand

Nominator First Name

* must provide value

Nominator Last Name

Nominator Job Title

* must provide value

Nominator's Department/Division/Center

* must provide value

Nominator's Phone

* must provide value

Nominator's Email

* must provide value

Relationship to Nominee

* must provide value

Expand

Two letters of support are required in addition to this nomination form. Provide the contact information of the 2 individuals who will be providing letters of support (LOS). Somebody other than the nominator is preferred, but not required.

The letter has a required format, OCR will contact them directly with the required template. Submitting a letter without this format will require re-submission.

1ST LETTER OF SUPPORT

Letter 1 - Submitter's First Name

* must provide value

Letter 1 - Submitter's Last Name

* must provide value

Letter 1 - Submitter's Phone

* must provide value

Letter 1 - Submitter's Email

* must provide value

2ND LETTER OF SUPPORT

Letter 2 - Submitter's First Name

* must provide value

Letter 2 - Submitter's Last Name

* must provide value

Letter 2 - Submitter's Phone

* must provide value

Letter 2 - Submitter's Email

* must provide value

Thank you for your nomination. Your nominee will be notified of your support.

We will also reach out to your Letter of Support Providers.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.