2018 AAOS Diversity Award

Nomination Form

  • Deadline for nominations:JUNE 19, 2017
  • Please complete this nomination form, in its entirety, and email to . Please also submit supporting materials, including candidate’s color photo, CV, and at least two letters of recommendation.
  • Please email or call 847-384-4163with questions or for additional information.

Sponsor Information

Name:

Address:

Telephone:

Fax:

Email:

Candidate Information

Name:

Address:

Telephone:

Fax:

Email:

How many years have you known the candidate?

What is your relationship to the candidate?

Candidate’s age:

Is the candidate willing to attend the 2017 Annual Meeting in Orlando, Florida, to receive the award, if chosen?

Yes: No:

  1. Describe what activities the candidate is/was involved in that promote diversity? For how long?
  1. What is/was the candidate's role in recruiting people from diverse ethnicity/gender into the field of orthopaedics?
  1. Has the candidate advanced diversity in orthopaedics by his/her own initiative or was it required by virtue of a role or position he/she held?
  1. Describe the candidate's mentoring activities beyond the usual role of teaching residents or fellows.
  1. How have the candidate’s activities in the diversity arena made a direct impact in providing orthopaedic care to underserved populations?
  1. How does the candidate affect improvement in healthcare disparities in his/her community? Describe how the candidate delivers culturally competent care in his/her community.
  1. How has the candidate made long-lasting improvements in the diversity arena that will persist beyond his/her direct involvement? Can the candidate’s contributions be reproduced or instituted elsewhere or on a national level? Please describe:
  1. How many people have been directly affected by the candidate’s work and over what time period? Has the candidate previously been recognized for his/her mentoring/diversity activities? Please briefly describe the type of recognition/award he/she received:
  1. Please list any materials the candidate has authored that address diversity, culturally competent care or health care disparities in orthopaedics:
  1. Please describe any additional contributions the candidate has made to issues of diversity, culturally competent care or health care disparities in or beyond the orthopaedic arena:
  1. How does the candidate lead by example and embody the values of diversity in orthopaedics? How has the candidate trained others to carry on his/her work and/or expand his/her overall impact in the long-run? Please describe:
  1. Why do you believe the candidate should be considered for the AAOS Diversity Award?

END OF QUESTIONNAIRE (12 QUESTIONS TOTAL)

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