Form - Physician Leadership Development Application

Provider First Name

Provider Last Name

Credentials

WakeMed Employee ID

Current Position

Length of time in current role

Practice Name

Number of years employed/credentialed at WakeMed

Eligibility Requirements

Completed Communication in Healthcare courseCompleted Communication in Healthcare course

Practicing Physician or APP for at least 3 years on WakeMed Medical Staff

Demonstrates respect for people by supporting and nurturing the well-being of self and others.

Provides clear, honest, professional and appropriately transparent communication to others.

Maximizes teamwork by collaborating at all levels, successfully fostering relationships and leveraging strengths.

Demonstrates commitment & accountability by soliciting and applying feedback for performance improvement.

Demonstrates the ability to be optimistic and resilient when facing constant changes in health care.

Why do you want to be a leader at WakeMed?

What do you hope to accomplish by participating in the program?

Please list all committees and/or professional organizations in which you have been actively involved.

What are three words others would use to describe you?

Reference #1: Name

Reference #1: Title

Reference #1: Email

Reference #1: Relationship to program applicant

I agree to Terms and Conditions