Royal College of General Practitioners, Mersey Faculty

							                                                                    Wessex Faculty
                                                                    Awards Evening 2012


        RCGP Award – Nomination Form for Patients
Criteria

This award is for general practitioners or their team for outstanding performance in 2011/12.

*        Please note that the judges require evidence of innovation and/or commitment above that
         expected from a high quality NHS primary care service


To nominate a member of staff at your local practice for a prize

Please send a written submission to the Wessex Faculty office by completing the form below. Emailed
electronic and postal versions are welcome. The following criteria apply:

1.         The nominated person or team should be working in primary care for an average of 1 day or more
           per week.
2:         We will contact the person you nominate to ask them to certify that they are of good standing with
           no outstanding complaints etc.

Our Contact details:

Wessex Faculty RCGP
Suite 3 Fosse House
East Anton Court
Icknield Way
Andover
Hampshire
SP10 5RG

Email: Wessex@rcgp.org.uk
Phone: 01264 355013




     The nominations will be entered into a number of categories, and the winners will be announced
                                                 at the

                         Wessex Faculty Awards Evening, Friday 22nd June 2012
                                                              Wessex Faculty
                                                              Awards Evening 2012



                                      RCGP Award
Your Name

Your phone number and/or email address (in
case we need further information)
Member of staff or team you are nominating

Surgery name and address




Surgery phone number

Please write your submission of 200-500 words describing why the nominee is worthy of an award: