Nomination Form for PT & PTA of the Year

Arizona Physical Therapy Association - PT & PTA of the Year Call for Nominations 

Instructions:
Nominating criteria: Must be a current member of the American Physical Therapy Association (AzPTA)
 
Submit
o      Nomination form
o      Curriculum Vitae (2-3 pages – do not include educational courses attended)
o      Letters of support are encouraged, but not required
 
Important Dates:         September 1, 2010: Deadline for Submission of Nominations
                                 October 2, 2010: Presentation of Award at the AzPTA Fall State Meeting
 
Please choose the areas pertaining to your nominee and elaborate on the salient points listed. Must have at least 3 of the following areas of excellence:
 

Clinical Skills
Community Service
Association Activities
o      Years of experience
o      Religious Community Involvement
o      Offices held
o      Practice specialization area
o      Civic Community Involvement
o      Board positions held
o      Teaching contributions
o      School Involvement
o      Committee activities
o      Mentoring contributions
o      Government Activity
o      Meeting attendance (region, state, national)
o      Post graduate degrees
o      Non-profit agencies
o      Presentation at meetings (region, state, national)
 
o      Neighborhood Involvement
o      Advocacy (federal affairs, state affairs, PAC, etc.)
Administration/Professional Leadership
o      Charitable foundations
o      Political activities in support of the association
o      Practice consultation
o      Volunteer Activities
o      Task force appointments 
 
o      Clinical management
 
 
o      Administration
Educational Activities
Research
o      Personnel management
Teaching of:
o      Poster presentations
o      Mentoring
o      In-services
o      Platform Presentations
o      State Board of PT
o      Continuing education
o      Case studies (published or presented)
o      Federation activities
o      Seminars
o      Participation in ongoing clinical research
o      Advocacy
o      Professional curriculum
o      Published research
 
o      Clinical instruction
o      Presentation of research at meetings (region, state, national, facility)

 

Click here for a downloadable form.

Name of Nominee *
Number of Years as APTA Member *
Telephone Number for Nominee *

Please enter N/A if you do not know the email address.
Email Address of Nominee *
Name of Nominator *
Email Address of Nominator *
Telephone Number of Nominator *

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.


 
Paste the Resume or Curriculum Vitae of the Nominee (please omit continuing education) *

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on the Clinical Skills of the Nominee

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on the Research Skills of the Nominee

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on the Community Service Activities in Which the Nominee is or Has Been Engaged

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on the AzPTA Activities in Which the Nominee is or Has Been Engaged

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on Educational Activities in Which the Nominee is or Has Been Engaged

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Provide Information on Administration/Professional Leadership Activities in Which the Nominee is or Has Been Engaged

In order to ensure the review process is accurate, use the Text Editor to format your entry properly. We recommend the use of bullets or numbering. Please do not paste photos or graphics.
Other Comments About the Nominee

 


 
Paste a Copy of Letter of Support #1

Name of Author of Letter of Support #1

 


 
Paste a Copy of Letter of Support #2

Name of Author of Letter of Support #2

 


 
Paste a Copy of Letter of Support #3

Name of Author of Letter of Support #3




Arizona Physical Therapy Association
3933 South McClintock Drive, Suite 505
Tempe, AZ 85282
602.569.9101 or 800.264.APTA (2782)
Fax: 480.603.4141
 info@aptaaz.org