2027 Community Surgeon Achievement Award Survey

OTA AFA Community Surgeon Achievement Award Nomination Application

Awarded to an individual who has primarily practiced in a community setting while also providing significant contributions at the local, state, national, or international Community levels that provide and/or improve Orthopaedic Trauma Care.

Complete the application to nominate a colleague. Please note that once you begin the application, you cannot save your progress and return later. We recommend drafting your responses in a separate document and copying them into the form when you’re ready to submit.

Please note: Information provided in this application may be incorporated into the award presentation script and shared publicly during the Annual Meeting.

1.Please fill in the following fields:(Required.)

Name:

Email:

Phone number:

2.Who are you nominating?(Required.)

3.My nominee meets the following eligibility requirements:
- An active, Board certified, community orthopaedic trauma surgeon.
- A current member of the OTA.(Required.)

Yes

4.Describe how your nominee has demonstrated outstanding community orthopaedic contributions in the communities he/she serves including describing the community itself: location, demographics, challenges met to serve (limit 250 words).(Required.)

5.Describe how your nominee has demonstrated an ongoing commitment to the advancement of orthopaedic research and education at the community level (limit 250 words).(Required.)

6.Describe your nominee's personal qualities of integrity, compassion and leadership in orthopaedic trauma.(Required.)

7.Upload Nominee CV - or email to erffmeyer@ota.org

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