You may nominate an individual for the 2017 James Pattee Award by completing the information requested below. Nominations will be accepted until November 18, 2016.

Internet Explorer Users:

We recommended that you submit our forms using a modern compliant browser such as an up-to-date version of Chrome, Firefox, or Safari and avoid using MS Internet Explorer, especially older versions, which present some compatibility problems.

2017 James Pattee Award for Excellence - Online Nomination Form

Nominee's Personal Information

Page 1 of 4

The information on this page pertains to the nominee's personal information.

First Name(*)
Please provide the nominee's first name.

Last Name(*)
Please provide the nominee's last name.

Credentials
Invalid Input

Organization
Invalid Input

Address
Invalid Input

City
Invalid Input

State
Invalid Input

Zip
Invalid Input

Country
Invalid Input

Please provide the country only if it's not the US.

Phone
Invalid Input

E-mail(*)
Invalid email address.

 

Nominee's Qualifications

Page 2 of 4

The information on this page pertains to the nominee's qualifications for the award.

Community and Professional Standing
Invalid Input

Please indicate whether the nominee is a physician or advanced practitioner in good standing with the community and profession.

Active in the Field
Invalid Input

Please indicate whether the nominee is active in the field of post-acute and long-term care medicine.

AMDA Member
Invalid Input

Please indicate whether the nominee is an AMDA member in good standing.

Board Status
Invalid Input

Please indicate the nominee is NOT a current Officer on the AMDA, APBLM or the Foundation boards by selecting Yes, otherwise leave unchecked.

Contributions
Invalid Input

Dr. Pattee recognized the need for long-term care education and became a leader in LTC education. In 250 words or less, please list specific contributions that the nominee has made to advance the educational goals of AMDA, and as a leader in PA/LTC education across the PA/LTC continuum.

 

Submitter's Information

Page 3 of 4

The information on this page pertains to you as the submitter.

First Name(*)
Please provide the submitter's first name.

Last Name(*)
Please the submitter's last name.

Credentials(*)
Invalid Input

Organization(*)
Invalid Input

Address(*)
Invalid Input

City(*)
Invalid Input

State(*)
Invalid Input

Zip(*)
Invalid Input

Country
Invalid Input

Please provide the country only if it's not the US.

Phone(*)
Invalid Input

E-mail(*)
Invalid email address.

 

Validation Check

Page 4 of 4

The information on this page pertains to the security and validation of this submission.

Captcha(*)
Captcha
  RefreshInvalid Input

Type the four lower case characters shown in the box above on the left into the box on the right and click Submit. You may click the Refresh link above as many times as you need to until you're confident you see the letters clearly.