Honorary Membership Nomination Form

Honorary Membership Nomination Form

This form is in accordance with: Honorary Membership Proposal Submissions BOD R09-09-05-07 & Honorary Membership Proposals BOD R06-75-11-26

The following person is nominated by the Chapter for consideration as an Honorary Member of the American Physical Therapy Association:

Nominee Contact Information

Name:

Mailing Address:

Phone:

E-mail:

Nominating Chapter Contact

Name:

Mailing Address:

Phone:

E-mail:

Supporting Documents – Please attach the following:

• Letter of nomination (Sample Nomination Letter – See appendix A)

• Curriculum vitae or resume (Sample Curriculum Vitae – See appendix B)

• Proposed resolution language – (Sample Resolution Language – See appendix C)

You may include any other appropriate background materials.

Please send all materials by mail to: APTA, Attn: Honors and Awards/Member Engagement,
1111 N Fairfax Street, Alexandria, VA 22314 -1488 or by e-mail to .

Approved by Chapter:

Signature of Chapter President Date

Appendix A

Sample Nomination Letter

Note: The names used in this letter are fictitious

Date

APTA Board of Directors

1111 N Fairfax Street

Alexandria, VA 22314-1488

RE: Nomination of Bill Jones, PT, PhD, for Honorary Membership in the APTA

Dear Board of Directors:

The [insert chapter name] is pleased to support the nomination of Bill Jones, PT, PhD, for consideration for Honorary Membership in the APTA. Dr. Jones’ contributions to the profession of physical therapy are significant and qualify him for this important APTA membership category.

Dr. Jones’ has made the following contributions to physical therapy: [In this section, please discuss the depth and breadth of the contributions.]

Thank you for your consideration and support of the nomination of Bill Jones, PT, PhD for honorary membership in the APTA.

Sincerely,

Vincent Thomas, PT, PhD

[Insert title at Chapter]

Appendix B

Sample Curriculum Vitae

Note: A Curriculum Vitae is an account of one’s career and qualifications

BIOGRAPHICAL

Name: / Birth Date:
Home Address: / Social Security #:
Business Address: / E-mail Address:
Business Phone: / Cellular Phone:
Fax:

EDUCATION

List all post-secondary education completed in reverse order:

·  Institution name

·  Institution address

·  Degree earned, year of graduation/completion

·  Concentration of study

·  Dates attended

Dates Attended / Degree and Year Earned
Concentration of Study
Institution
Institution Address
Dates Attended / Degree and Year Earned
Concentration of Study
Institution
Institution Address

LICENSURE AND CERTIFICATION

List all licenses and certifications you hold. Include:

·  Licensing or certifying organization (state board, professional organization, etc.)

·  License or certificate number

·  Dates

Certifying Organization / License / Certificate Number / Dates Valid

*Maintain separate hard copy files of all certificate and license information

PROFESSIONAL EXPERIENCE

List relevant work experience including positions which are academic, clinical, consultative, administrative, and CI experience. List information in reverse chronological order and include:

·  Dates

·  Title

·  Organization name

·  Address

·  Supervisor’s name and telephone

·  Job responsibilities/accomplishments

o  Direct patient care responsibilities

§  Types of patient/client and diagnoses/treatments

§  Total clinical hours

o  Indirect patient care responsibilities

§  Administration

§  Education

§  Research

§  Special assignments/projects

Dates / Title
Organization Name
Address
Description
·  Direct Patient Care
·  Indirect Patient Care
Supervisor Name/Telephone
Dates / Title
Organization Name
Address
Description
·  Direct Patient Care
·  Indirect Patient Care
Supervisor Name/Telephone

PROFESSIONAL DEVELOPMENT*

Include professional development/continuing education completed. List information in reverse chronological order:

·  Workshop title / CE title

·  Date(s)

·  Location (City, State)

·  Number of Continuing Education Units (CEUs)

·  Presenter

·  Sponsor and address

·  Length of presentation

Date(s) / Title
CEUs / City, State
Sponsor & Address
Presenters
Date(s) / Title
CEUs / City, State
Sponsor & Address
Presenters

*It is essential to maintain a permanent record of your CE documentation. Documentation includes course title, description, objectives, schedule and certificate of completion.

TEACHING ACTIVITIES

COLLEGE / UNIVERSITY COURSES*

·  Course Title

·  Date

·  Location

·  College/University

·  Length of presentation

·  Number of continuing education units/contact hours

·  Topic, description & objectives for all portions you presented

Date / Course Title
Credit Hours / Location
College/University
Length of Course
Topic (if different from course title)
Description & Objectives
Date / Title
Credit Hours / Location
College/University
Length of Course
Topic (if different from course title)
Description & Objectives

*Maintain separate records of involvement in student clinical education (names of students, dates of affiliation, level, and area of practice)

POST-GRADUATE CONTINUING EDUCATION*

Date / Title
CEUs / Location
Contact Time with Learners** / Sponsor
Topic, Description and Objectives
Date / Title
CEUs / Location
Contact Time with Learners** / Sponsor
Topic, Description and Objectives

*It is essential to keep a permanent record of your presentation(s). Documentation includes all of the above plus summary of participant evaluations.

**Contact time is the actual amount of time that you are presenting and/or interacting with the learners.

CLINICAL INSTRUCTION

List roles/activities related to clinical education of PT’s and PTA’s at all levels of education.

·  Dates

·  Role/position

·  Summarized data

o  Number of students

o  Level of instruction

o  Duration of affiliation

Dates / Role / Summarized Data (yearly basis)

*Maintain separate records of involvement in student clinical education (names of students, dates of affiliation, level, and area of practice)

COMMUNITY-BASED EDUCATION

Date / Title
Location
Sponsor
Length of Presentation
Description
Date / Title
Location
Sponsor
Length of Presentation
Description

SCHOLARLY ACTIVITIES

PROFESSIONAL PRESENTATIONS

Include platform or poster presentations at professional meetings and invited lectureships such as McMillan Lecture or Maley Lecture:

·  Title of presentation

·  Date

·  Location

·  Length of presentation

·  Brief description

·  Sponsors

Date / Title
Location
Sponsor
Length of Presentation
Description
Date / Title
Location
Sponsor
Length of Presentation
Description

PUBLICATIONS

·  Authorship of book chapters, peer reviewed journal articles, research abstracts, reviews or commentaries and case study or case study reports.

o  Use AMA format for full bibliographic reference

o  A useful website for AMA citation styles is: http://healthlinks.washington.edu/hsl/styleguides/ama.html

Sample AMA format citation for Journal Article:

Noonan V, Dean E:Submaximal exercise testing: clinical application and interpretation.Phys Ther 2000 Aug;80(8):782-807

·  Professional activities related to scholarship includes grant proposals, writings you have edited such as books, peer reviewed journals, and submissions to outcomes database such as Hooked on Evidence, and manuscript reviews. List in reverse chronological order:

o  Role (editor, reviewer, board member, grant writer)

o  Title of work

o  Author (if applicable)

o  Publication date

o  Provide bibliographic reference or brief description of work

Role
Title of Work
Author
Publication Date
Bibliographic Reference/Brief Description
Role
Title of Work
Author
Publication Date
Bibliographic Reference/Brief Description

RESEARCH ACTIVITIES

List current research projects:

Title / Description
Length of Project
Responsibility Within Project
Funding Source
Amount of Funding
Title / Description
Length of Project
Responsibility Within Project
Funding Source
Amount of Funding

PROFESSIONAL MEMBERSHIP & ACTIVITIES

List all professional or scientific societies that you are a member of. Include the following:

·  Dates

·  Association or society name

·  Membership status

·  Indicate if you held a position in addition to being a member and the years you held position

·  Brief description of accomplishments

Dates / Association/Society
Membership Status
Positions/Offices Held and Dates
Brief Description of Accomplishments
Dates / Association/Society
Membership Status
Positions/Offices Held and Dates
Brief Description of Accomplishments

PROFESSIONAL SERVICES

List committee membership, association activities, content expert/consultant, or other profession related activities. Information listed should be organized in reverse chronological order and include:

·  Dates

·  Position held/title

·  Committee name/organization

·  Description (bulleted)

o  Accomplishments

Dates / Title/Position
Committee Name/Organization
Description
Accomplishments
Dates / Title/Position
Committee Name/Organization
Description
Accomplishments

HONORS/AWARDS

List honors and awards you have received throughout your educational and professional work experiences. Examples of this may be university dean’s list, professional or academic fraternities, and organization recognition. Information to include is:

·  School/organization bestowing honors/awards

·  Brief description of award

·  Date received

Date Received / School / Organization
Description of Honor/Award
Date Received / School / Organization
Description of Honor/Award

UNIQUE QUALIFICATIONS

List any additional qualifications you possess that may compliment your professional knowledge and skills such as sign language, fluency in a foreign language, and advanced computer literacy.

Appendix C

Sample Resolution Language

Formatting Notes:

·  A resolution should always begin with the words “ELECTION TO HONORARY MEMBERSHIP IN THE AMERICAN PHYSICAL THERAPY ASSOCIATION:” in all capital letters followed by the nominee’s name.

·  In the “Whereas” section - the first letter of “Whereas” and first letter of the word following “Whereas” is always capitalized. “Whereas” is always followed by a comma, and sentences starting with “Whereas” should end with a semi-colon.

·  At the end of the clause immediately preceding the last “Whereas” statement of the resolution, place the word “and” after the semi-colon followed by a comma.

·  The first letter of “Resolved” and first letter of the word following “Resolved” is always capitalized. “Resolved” is always followed by a comma, and the sentence should end with a period. There may be more than one “Resolved” in a resolution.

ELECTION TO HONORARY MEMBERSHIP IN THE AMERICAN PHYSICAL THERAPY ASSOCIATION: [insert name of nominee – e.g. Bill Jones, PT, PhD]

Whereas, Dr. Bill Jones has made significant contributions to the practice of physical therapy;

Whereas, Dr. Jones has co-authored over 100 peer reviewed articles with physical therapists; and

Whereas, Dr. Jones was instrumental in conducting research in ten studies that contributed significantly to the understanding of a major illness commonly seen in physical therapist practice; and,

Whereas, Dr. Jones has advocated for and won increased funding for physical therapy research

Resolved, That Dr. Bill Jones be elected as an Honorary Member of the American Physical Therapy Association.

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