Nomination Form for Geriatrician And

Nomination Form for Geriatrician and

Gerontologist of the Year

2014

Arizona Geriatrics Society

500 North 3rd Street ASU NHI-1

Phoenix, AZ 8500

Phone: (602) 265-0211

Fax: (602) 274-8086

ARIZONA GERIATRICS SOCIETY

GERIATRICIAN/GERONTOLOGIST OF THE

YEAR AWARDS

Each year, the Arizona Geriatrics Society recognizes and honors an exemplary

Arizona physician and an outstanding health care professional who have devoted

their professional lives to the care of the elderly or have made significant contribu-

tions to geriatric medicine or in the field of gerontology. Nominations can only be submitted by members of the Arizona Geriatrics Society; however; membership is not required for the nominee.

§  The Geriatrician Award is open to all licensed physicians

§  The Gerontology Award is open to all Arizona health care professionals

SELECTION CRITERIA

The following criteria will be evaluated:

·  Scope of service to older adults

·  Length of commitment or service

·  Impact in the community as a result of the nominee’s activities

DEADLINE TO NOMINATE

Monday, October 27th

NOMINATION INFORMATION (Please attach additional sheets if necessary)

I wish to nominate the following person for the Arizona Geriatrics Society to receive:

Geriatrician of the Year Award* Gerontologist of the Year Award*

Name: ______

Address: ______

City/State/Zip: ______

Phone: ______Fax: ______

Email: ______

Organization: ______

Title: ______

Organization Address: ______

City/State/Zip: ______

Nominations must be postmarked/email dated by Monday, October 27th.

Mail to: Arizona Geriatrics Society

500 North 3rd Street, ASU NHI-1

Phoenix, AZ 85004

Email:

Phone: (602) 265-0211

Fax: (602) 274-8086

* Awards will be presented at the Society’s annual membership meeting in November 2014.

Describe nominee’s length of time in service to older adults.

Specifically describe the contributions/activities of the nominee.

What has been the impact in the community due to these contributions?

List any credentials, any unique qualifications related to this work.

Please relate any additional information relating to the nominee’s accomplishments.

Nomination submitted by: (must be a member of the Arizona Geriatrics Society)

Name: ______

Address: ______

City/State/Zip: ______

Signature: ______