Award Nominations

This form is used for all professional award nominations. Please note you are asked to include 1 letter of support with your submission!

NAME OF NOMINEE:*
NAME OF OSLHA AWARD:*
- Honors of the Association
- Fellow of the Association
- Elwood Chaney Outstanding Clinician Award
- Nancy Bailey Award of Appreciation
- Advocacy Recognition Award
Nominee Information
NOMINEE PHONE:*
NOMINEE EMAIL:*
NOMINEE ADDRESS:*
NOMINEE CITY / STATE / ZIP CODE:*
Nominee Qualifications
PROFESSIONAL MEMBERSHIPS AND NUMBER OF YEARS:*
CURRENT JOB TITLE/POSITION(S):*
Hidden
PREVIOUS JOB TITLE/POSITION(S):*
EDUCATION:*
CERTIFICATION(S):*
LOCAL CONTRIBUTIONS/OUTSTANDING CONTRIBUTIONS:*
Please explain why this nominee is an outstanding candidate for this recognition and include a description of the efforts & the measurable outcomes/results that contribute to the award recognition being considered.
Letter of Support
Procure and submit 1 letter of support from a supporter/contributor (other than the nominator) who affirms the nominees contributions and/or provides additional evidence to support the nomination.
Letter of Support - File Upload*
Please upload 1 letter of support
Accepted file types: pdf, doc, docx, Max. file size: 10 MB.
Lead Nominator Information
NAME OF LEAD NOMINATOR:*
LEAD NOMINATOR EMAIL:*
LEAD NOMINATOR PHONE:*

Nominee Information