California Cancer Registrars Association
Distinguished Service Award Nomination Form

1. Service to the association as evidenced in at least one or more of the following areas.

A. Local component chapter participation, including serving as an officer, committee chairman, and/or committee member.
B. State participation in CCRA, including serving as a board member, committee chairman, special appointment, and/or committee member.
C. National participation in NCRA, including serving as a board member, committee chairman,special appointment, and/or committee member.

2. Professional achievement as evidenced in at least one or more of the following areas. 

A. Development or refinement of professional theory and/or techniques documented through presentation or publication.
B. Dissemination of knowledge of practice through consultation to others in the field. Recognized resource person in area of specialty.
C. Successful completion of NCRA certification and maintenance of certified status.

3. Conducting research and publication activities in at least one or more of the following areas.

A. Publication of written material in reference journal articles, association publications.
B. Publication of written material in monograph, instructional guides, position papers or books.

4. Education leadership as evidenced in at least one or more of the following areas.

A. Presenter at local, state, regional or national workshops, meetings, seminars or conferences.
B. Community and/or patient education.

5. Other contributions to the health care profession.

6. Contributions to society through religious, civic, or other community activities.

Nomination Submitted by:

(Can be an individual or a group; if nominated by a group, please list an individual as a contact person.)

Contact information of person submitting the nomination:

Contact Name(Required)
Contact Address(Required)

Nominee Information:

Nominee Name(Required)
Nominee Address(Required)
Current Member?(Required)

Reason for nominating the individual:

If you have any supporting documents, please upload them here:

Max. file size: 256 MB.
Max. file size: 256 MB.

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