You may nominate an individual for the 2018 William Dodd Founder's Award by completing the information requested below. Nominations for the  2018 Dodd Award are due November 17, 2017.

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2018 William Dodd Founder's Award - Online Nomination Form

Nominee's Personal Information

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The information on this page pertains to the nominee's personal information.

First Name(*)
Please provide the nominee's first name.

Last Name(*)
Please provide the nominee's last name.

Credentials
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Organization
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Address
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City
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State
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Zip
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Country
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Please provide the country only if it's not the US.

E-mail(*)
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Nominee's Qualifications

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The information on this page pertains to nominee's qualifications for the award.

Community and Professional Standing
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Please indicate whether the nominee is a physician or advanced practitioner in good standing with the community and profession.

Active in the Field
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Please indicate whether the nominee is active in the field of post-acute and long-term care medicine.

AMDA Member
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Please indicate whether the nominee is an AMDA member in good standing.

Board Status
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Please indicate the nominee is NOT a current Officer on the AMDA, APBLM or the Foundation boards by selecting Yes, otherwise leave unchecked.

Narrative
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In 250 words or less, please list specific contributions the nominee has made to build the organizational strength, image, and mission of AMDA, and advance the Society's goals to improve care delivered to patients throughout the long-term care continuum.

 

Submitter's Information

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The information on this page pertains to you as the submitter.

First Name(*)
Please provide the submitter's first name.

Last Name(*)
Please the submitter's last name.

Credentials(*)
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Organization(*)
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Address(*)
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City(*)
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State(*)
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Zip(*)
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Country
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Please provide the country only if it's not the US.

Phone(*)
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E-mail(*)
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Validation Check

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The information on this page pertains to the security and validation of this submission.

Captcha(*)
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Type the four lower case characters shown in the box above on the left into the box on the right and click Submit. You may click the Refresh link above as many times as you need to until you're confident you see the letters clearly.