FACRM Nomination Form

FACRM Nomination Form

 

To nominate a colleague for recognition as a Fellow of ACRM, please complete the form below and be sure to click SEND to submit your nomination.

If you need assistance with the form, please contact Cindy Robinson, +1.757.377.8904

If you have questions about the nomination process, please contact Terri Compos, +1.760.436.5033

 

Date: (mm-dd-yyyy)

Name of Nominee:

Nominee's Affiliation:

Nominee's Street Address:

City:

State/Province:

Postal Code:

Country:

Nominee Email *

Nominee Phone:

I. Outstanding Service to ACRM
Describe service to ACRM that includes: [1] attendance at three (3) or more ACRM meetings in the last five (5) years; [2] presentation at two (2) or more ACRM meetings in the last five (5) years; [3] sustained active membership on at least one ACRM committee, interdisciplinary special interest group, task force, or networking group, or other extensive professional activity that advances the mission of the ACRM and its members.

II. Outstanding Contributions to Rehabilitation Medicine
List specific national level contributions in at least two areas selecting from clinical practice, research, education, and administration. Examples include: [1] sustained, extensive, or significant contribution to the body of literature, [2] multiple years of service as a key clinician in medical rehabilitation, [3] multiple years of service as a senior level manager and/or leader in medical rehabilitation, [4] multiple years of service as senior educator in a prominent training program in medical rehabilitation, [5] writer/editor of a core medical rehabilitation-related textbook and/or editor of a major rehabilitation journal, [6] service on the board of a national or major regional/state medical rehabilitation-related organization other than ACRM, [7] other leadership/activity in a national or major regional/state medical rehabilitation-related organization other than ACRM (e.g., committee chairperson, task force person), [8] service on a major medical rehabilitation-related advisory group or on the board of a national consumer disability organization, [9] Service on national medical rehabilitation research, clinical, and/or educational advisory committees or on the editorial board of a rehabilitation journal.

Your Name:

Your Affiliation:

Your Street Address:

City:

State/Province:

Postal Code:

Country:

Your Email *

Your Phone