2022 OTA AFA Community Surgeon Achievement Award

OTA AFA Community Surgeon Achievement Award Nomination Application

Complete the application to apply or to nominate a colleague.

Then email the nominees CV to Kiersten Davison: davison@ota.org.

Deadline: May 31, 2022

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* 1. Please fill in the following fields:

Name:

Email:

Phone number:

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* 2. Who are you nominating?

self

colleague

Colleague's Name:

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* 3. I (or my nominee) meet the following eligibility requirements:
- An active, Board certified, community orthopaedic trauma surgeon.
- A current member of the OTA.
- I agree to attend the 2022 OTA Annual Meeting in Tampa, Florida.
- I understand that I may be asked to give a short presentation at this meeting.

Yes

No

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* 4. Describe how you/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).

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

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* 6. Describe you or your nominee's personal qualities of integrity, compassion and leadership in orthopaedic trauma.