2018 Luther L. Terry Awards

Nomination Form

I. Award Category (Choose one.)

□ The Young Pioneer Award
□ The Outstanding Individual Leadership Award
□ The Distinguished Career Award

II. Nominator’s Contact Information

Name (including credentials): / E-mail:
Current Position (title, employer, and a brief description of position and responsibilities): / Telephone (day and evening):
Address: / Fax:

III. Nominee’s Contact Information

Name (including credentials, if an individual): / E-mail:
Current Position (title, employer, and a brief description of position and responsibilities): / Telephone (day and evening):
Address: / Fax:

IV. Questions

Please answer each question in 250 words (one typed page) or less and provide explicit examples where possible.

1.  What is the nominee’s involvement with the public health/tobacco control field?
2.  How has the nominee demonstrated consistent excellence in tobacco control? (If Young Pioneer Award: How has the nominee demonstrated that he or she is an emerging leader in the tobacco control field?)
3.  In what ways has the nominee served as a role model for colleagues?
4.  What unique qualities enhance the nominee’s approaches to tobacco control?
5.  Provide one or more specific examples of the nominee’s unique accomplishments as a tobacco control advocate.
6.  What innovative approaches has the nominee used to contribute to tobacco control?
7.  Given the awards criteria listed in the Call for Nominations, please explain in 1-2 sentences how the nominee fits into this award category.

V. Two Letters of Support

Two letters of support must be included with the nomination. One of the letters should be from an agency or association with which the nominee is not directly affiliated. Organization letters should be co-signed by leaders of the group. Members of the awards selection committee may not provide written support as part of a nomination package. Letter writers are encouraged to include relevant quotes, anecdotes, and experiences that illustrate the dedication and concern of the nominee.

VI. Nominee’s Biography: Curriculum vitae and summary of tobacco control activities

Please attach the nominee’s curriculum vitae and a summary of his/her activities in the world of tobacco control.

Please email the completed nomination form, 2 letters of support, curriculum vitae and summary of activities to by September 29, 2017.

The entire nomination package should be a MAXIMUM of 15 pages.