Joseph Dutkowksy, MD Clinician of the Year Award Nomination Form

 

Please fill in the form below and submit when complete.

Should you require a PDF of this form to fill out manually, please contact Kelsey Massyk at kmassyk@cpstate.blackdogsitetesting.com to request a downloadable copy.

 

 

Purpose

Honors a clinician who has worked to positively change the lives of people with intellectual and developmental disabilities through their work within a CP State Affiliate or related program.

Eligibility

A clinician in a CP State Affiliate or related program who has advocated for health equity, shown a commitment to improving the diagnoses and treatment of people with I/DD. This includes, but is not limited to, developing innovative and appropriate protocols, improving the general clinician knowledge and understanding of effective treatments, and/or other efforts to improve the quality of healthcare services available.

Nominee Information

Name of Nominee(Required)
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        Nominating Party Information

        Nominating Party Name(Required)
        Mailing Address(Required)
        Attestation(Required)