AMA (WA) Junior Doctor
of the
Year 2015
(Dr Camille Michener Legacy Award)
“Celebrating the outstanding contribution
of our Doctors in Training to the
Medical Profession and the Community”
About the Award
The annual AMA (WA) Junior
Doctor of the Year (Dr Camille
Michener Legacy Award) was
inaugurated in 2010 to
recognise the exceptional
contribution of Dr Camille
Michener to the Medical
Profession, her colleagues and
the patients she felt privileged
to serve. A $3,000 grant will be
awarded annually to the winner
of this prestigious Award.
This annual Award has been established
by Helen and Norm Michener, with the
assistance and support of the AMA (WA),
to honour the life and achievements
of their beloved daughter, Dr Camille
Michener, who tragically died in a car
accident on 24 July 2009.
The Award recognises the significant and
outstanding contribution of our Doctors
in Training to the Medical Profession and
the Community in areas such as teaching
and education; leadership and advocacy;
and doctor’s wellbeing and community
service. These were all activities and
values significant to Camille. The Award
establishes a fitting legacy to all that
Camille achieved in her short time with
us and will ensure that we celebrate
the ongoing contributions that our
Doctors in Training make amongst their
colleagues, the profession and in and for
the Community.
For further information about Dr Camille
Michener and the past winners of this
prestigious Award please refer to the
AMA (WA) website.
Eligibility and Criteria
The Award recognises a Doctor in
Training (DiT), i.e. Intern through to Senior
Registrar, who has been outstanding in
areas such as:
Teaching and Education;
Leadership and Advocacy;
Doctors’ Wellbeing; and
Community Service
The requirement is that the nominee
will have made a significant contribution
to the Medical Profession and the
Community beyond that expected
of Doctors in Training in their normal
working roles.
Conditions of Entry
• Nominations are to be on an official
form, the online form available at
camille.amawa.com.au or the form
within this brochure.
• The proposer must sign the
nomination form but does not need
to obtain the authorisation of the
nominee to submit an entry.
• The nominee must be a Doctor
in Training (i.e. Intern through to
Senior Registrar).
• Finalists must be a member of the
AMA (WA).
• The information provided to support
the nomination can be drawn from
current and previous years although
more recent activities may be given
greater weight in the assessment
phase. Activities undertaken as a
Medical Student can be included as
part of the nomination.
• All nomination information and
material remains the property of the
AMA (WA) Junior Doctor of the Year
Award Panel.
• All nomination information and
material can be utilised by the AMA
(WA) to publicly recognise the award
recipient and award finalists and
in promoting the achievements of
Doctors in Training in WA. Information
about the award finalists and winner
may be published in the AMA
(WA) monthly journal Medicus and/
or Med e-link.
• The decision of the Selection Panel is
final and no correspondence will be
entered into.
• Self-nomination is permissible.
Nominations must be received by 4.30pm
on Friday 1 May 2015. Nominations can
be hand delivered, emailed (as a PDF or
MS Word Document), mailed, faxed or
submitted online.
For details on the selection procedure
please refer to the AMA (WA) website.
Key Dates
Friday 27 March 2015
Call for nominations and entries
Friday 1 May 2015
Entries close at 4.30pm
Monday 4 May – Monday
25 May 2015
Panel identifies finalists and
winner.
Nominees will be notified if they
are shortlisted as a finalist.
Saturday 1 August 2015
Presentation of Award at the
AMA (WA) Awards and Charity
Dinner.
AMA (WA) Junior Doctor
of the
Year 2015
(Dr Camille Michener Legacy Award)
Please complete the form in full and
together with supporting material, post,
fax, email or deliver to:
Post
The Chairperson
AMA (WA) Junior Doctor of the Year 2015
C/- AMA (WA)
To Enter/Nominate
AMA (WA) Junior Doctor of the Year 2015
1. Complete Official Entry/Nomination Form
Nominees must be a Doctor in Training and all finalists are to be members of
the AMA (WA).
PO Box 133
2) Attach Documentation as follows:
NEDLANDS WA 6909
a. Provide a short statement of who is to be nominated and why. (Max 150 words)
Fax:
b. Provide a statement as to how the nominee has provided outstanding service to
performance within the Medical Profession and the Community. Demonstration
can be in areas such as:
Attention: The Chairperson
AMA (WA) Junior Doctor of the Year 2015
• Teaching and Education
Fax: 9273 3073
• Leadership and Advocacy
[Marked Confidential]
Email:
• Doctor’s Wellbeing and Community Service (Max 1,500 words)
c. To support the entry, it is allowable for the following information to be attached:
• Testimonials/References
[email protected]
• Newspaper/Media Clippings
Online:
An online nomination form is
available at camille.amawa.com.au
• Promotional material such as flyers, brochures, manuals that may have
been developed
Please ensure that you make reference to the support material in your entry and
clearly mark any attachments.
Please mark all correspondence Private and Confidential
Complete this form and submit.
Send support material by post or email
to the above address with the name of
the person nominating clearly marked.
d. If nominating yourself, describe the intended use of the $3000 prize money if
successful. (The expectation of the Award Selection Panel is that the prize money
will be used for ongoing professional development). (Max 200 words)
Note: If you are nominating another person, the AMA (WA) will contact your
nominee for this information.
3) Return entry/nomination form and supporting material
by 4.30pm Friday 1 May 2015
AMA (WA) Junior Doctor
of the
Year 2015
(Dr Camille Michener Legacy Award)
Entry/Nomination Form
AMA (WA) Junior Doctor of the Year 2015
To be completed, signed, attached to and forwarded with the response to the selection criteria.
SECTION A: YOUR DETAILS
Title
First Name
Surname
Position Held
Current Hospital/Place of Employment
Telephone (M)
(W)
(H)
Email
Address
Postcode
SECTION B: NOMINEE’S DETAILS
Please provide details of the Doctor in Training you are nominating below:
Nominee’s Name
Position Held
Current Hospital/Place of Employment
Telephone (M)
(W)
(H)
Email
Address
Postcode
Nominee’s Signature (Optional)
Date:
/
/
/
/
SECTION C: DECLARATION
I confirm the information contained in this entry is, to the best of my knowledge, true and correct
Signature
Date: