2017 Nomination Form: Geriatrician & Gerontologist of the Year Awards

Each year, the Arizona Geriatrics Society recognizes and honors exemplary and outstanding health care professionals who are passionate about caring for older adults and have made significant contributions in the field of geriatric medicine or gerontology.  Nominations can only be submitted by members of the Arizona Geriatrics Society; however, membership is not required for the nominee.
  • The Geriatrician of the Year Award is open to all Arizona licensed prescribers including physicians, nurse practitioners, physician assistants and pharmacists.
  • The Gerontologist of the Year Award is open to all Arizona health care professionals including nurses, social workers, case managers, therapists, psychologists and any other individual who is a non-prescriber.
 
Selection Criteria
The following criteria will be evaluated:
  • Demonstration of exemplary interprofessional geriatric practice or education
  • Impact in the community of employment as a result of the nominee's activities
  • Scope or length of service
 
Deadline to Nominate
Monday, October 9, 2017
 
Awards will be presented at the Society's annual membership meeting on October 20, 2017.

Questions can be directed to AzGS staff at AskUs@ArizonaGeriatrics.org or 602-265-0211.

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* 1. I wish to nominate the following person for the Arizona Geriatrics Society to receive:

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* 2. Nominee's Name

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* 3. Nominee's Title

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* 4. Nominee's Address

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* 5. Nominee's Phone

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* 6. Nominee's Email

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* 7. Nominee's Organization

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* 8. Describe the contributions/activities of the nominee that demonstrate interprofessional geriatric practice or education.

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* 9. Describe the nominee’s ability to affect meaningful change in the community where the nominee works. (Please be specific and describe the change and the resulting impact.)

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* 10. Describe additional qualities that make the nominee truly outstanding (creativity, professionalism, compassion, innovation, dedication, etc.). Provide examples.

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* 11. How does this individual and their accomplishments serve as an example for other practitioners and educators?

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* 12. Nomination submitted by:  (must be a member of the Arizona Geriatrics Society)

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* 13. Address

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* 14. Email Address

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* 15. Phone

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