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Gold Card Nomination Form

Through the presentation of the Gold Card, we provide a concrete way to recognize those who most embody humanism and compassion in the Jefferson community. Nominated by their colleagues and peers, Gold Card recipients serve as leaders in the community who, through their actions, improve the quality of patient care and challenge other professionals to practice medicine with as much their hearts as their minds. To nominate someone, please fill out the form below. At this time, only Physicians or Physicians in Training are eligible to receive the card. You will be informed in writing if your nominee is chosen.

--Recognition of Humanism Committee of the Gold Humanism Honor Society.

Submit a Nomination

Nominator's Name
Nominator's Email
Nominator's Role in Medicine

If Other, please specify:

Nominee's Name
Nominee's Role in Medicine
Why this individual should receive a Gold Card? Please use specific examples of behavior or actions deserving of this honor.
If this individual is selected to receive a Gold Card, who should present it? I would like to present the card myself.
I would like a Committee member to present the card.

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