NUPTAA Award Nomination

Alumni Awards Questionnaire

As the primary nominator of this nominee, please fill out the following questionnaire so that the awards committee might have more information on the nominee. Thank you. If you prefer a written application, download the .pdf and mail it to: Bill Healey, 645 N Michigan Ave Suite 1100, Chicago, IL 60611 All nominations will be considered completed when the nominee’s Curriculum Vitae and 3 letters of recommendation are received.

Your Name«

First and last name (with maiden name also if it has changed since your time at NU)

Email«

Your email address

Nominee's Name«

First and last name (with maiden name if it has changed since their time at NU)

Graduation Year«

of the Nominee

We need to have the nominee's address, phone numbers and/or email that he/she can be contacted by the awards committee.

Nominee's Email

Full Address of the Nominee

Include the street, city, state and zip code

Phone Number

Contact number for the nominee

Award«

The award you are nominating the above nominee for is which of the following NUPT Alumnus Awards

Distinguished Alumnus of the Year

Young Alumnus of the Year

Research Achievement Award

Please complete the following questions in an effort to provide a greater insight into the nominee’s involvement with physical therapy both professionally and in relation to NUPT:

In you own words, what do you feel the nominee has accomplished professionally that would meet the criteria of this award?«

One component of this award is based on the nominee’s contributions to Northwestern’s Department of Physical Therapy and Human Movement Sciences since his/her graduation. Please address the following areas of involvement:

a. Describe the nominee’s involvement in the NUPT student program over his/her career (i.e. clinical supervision or mentoring program, graduation speaker, etc.).

b. Describe the nominee’s involvement in the academic program at NUPT (i.e guest lecturer, member of panel discussion, course instructor, etc.).«

c. Describe the nominee’s involvement in the NUPT Alumni Association (i.e. Alumni weekend speaker, BOD member, attendee, etc.).«

Additional comments:

Fields marked with "«" are required.

Thank you again for your comments.