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 POSITION(S):*
PREVIOUS POSITION(S):*
EDUCATION:*
CERTIFICATION:*
LOCAL CONTRIBUTIONS/OUTSTANDING CONTRIBUTIONS (including a description of the efforts & the measurable outcome/results):*
Letter of Support
Procure and submit 1 letter of support from a supporter/contributor other than the nominator.
Letter of Support - File Upload*
Please upload 1 letter of support
Accepted file types: pdf, doc, docx.
Lead Nominator Information
NAME OF LEAD NOMINATOR:*
LEAD NOMINATOR EMAIL:*
LEAD NOMINATOR PHONE:*

Nominee Information