Nominee First Name*

Nominee Last Name*

Nominee Credentials*

Nominee Organization*

Nominee Address*

Nominee Address 2

Nominee City/Town*

Nominee State/Province* Nominee State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Nominee ZIP/Postal Code*

Nominee Email*

Nominee Phone*

Nominee's Professional Information

Check all that apply:* Check all that apply:* AMDA Member Certified Medical Director (CMD) Minimum 3 years experience as a Medical Director Experience as an Attending Physician in long term care

Experience in years*

Service History*

Facilities served and dates of service as medical director (e.g., Golden Age NH 2001-06).

Medical Director Activities*

Please include a list 7-10 examples of activities that the nominee leads in the following areas: team leader, clinical leader, community involvement and staff education. Examples: Team Leader Activites (e.g., established wound care team). Clinical Leader Activities (e.g., implemented practice guidelineon falls prevention). Community Involvment Activities (e.g., hold monthly advance directives 'clinics' at area senior center). Staff Education Activities (e.g., inservice topics, state or national presentations, etc.). *

Submitter's Information

Submitter First Name*

Submitter Last Name*

Submitter Credentials*

Submitter Organization*

Submitter Address*

Submitter Address 2

Submitter City/Town*

Submitter State/Province* Submitter State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Submitter ZIP/Postal Code*

Submitter Email*

Submitter Phone*

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Nominee Last Name*

Nominee Credentials*

Nominee First Name*

Nominee Address*

Nominee Organization*

Nominee City/Town*

Nominee Address 2

Nominee State/Province* Nominee State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Nominee ZIP/Postal Code*

Nominee Email*

Nominee Phone*

Nominee's Professional Information

Community and Professional Standing* Community and Professional Standing* Yes No

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

Active in the Field* Active in the Field* Yes No

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

AMDA Member* AMDA Member* Yes No

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

Board Member* Board Member* Yes No

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

Narrative*

In 250 words or less, please list specific contributions the nominee has made to build the organizational strength, image, and mission of AMDA, and advance the Society's goals to improve care delivered to patients throughout the long-term care continuum.

Submitter's Information

Submitter First Name*

Submitter Last Name*

Submitter Credentials*

Submitter Organization*

Submitter Address*

Submitter Address 2

Submitter City/Town*

Submitter State/Province* Submitter State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Submitter ZIP/Postal Code*

Submitter Email*

Submitter Phone*

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Nominee First Name*

Nominee Last Name*

Nominee Credentials*

Nominee Organization*

Nominee Address*

Nominee Address 2

Nominee City/Town*

Nominee State/Province* Nominee State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Nominee ZIP/Postal Code*

Nominee Email*

Nominee Phone*

Nominee's Professional Information

Community and Professional Standing* Community and Professional Standing* Yes No

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

Active in the Field* Active in the Field* Yes No

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

AMDA Member* AMDA Member* Yes No

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

Board Member* Board Member* Yes No

Please indicate if the nominee is a current Officer on the AMDA, APBLM or the Foundation boards.

Narrative*

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 PALTC education across the PALTC continuum.

Submitter's Information

Submitter First Name*

Submitter Last Name*

Submitter Credentials*

Submitter Organization*

Submitter Address*

Submitter Address 2

Submitter City/Town*

Submitter State/Province* Submitter State/Province*AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshirenNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Submitter ZIP/Postal Code*

Submitter Email*

Submitter Phone*

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