Grace Black Award of Honor Nomination Form – Occupational Therapy Association of Oregon

It’s OTAO’s greatest honor to recognize an OT/OTA who is a member of OTAO, and who has made continuing contributions to the OT profession. The nominee must be an OT/OTA practitioner with more than 10 years of experience, and have made an active and on-going contribution to OTAO for a period of more than 5 years.

Name *

First

Last

Person Nominating Candidate

Title/Organization *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Award Candidate's Name *

First

Last

Grace Black Award Candidate

Award Candidate's Title/Organization of Candidate (if known) *

Award Candidate's Address (if known)

Award Candidate's Phone Number (if known)

Award Candidate's Email *

Award Candidate's number of years of sustained activity in OTAO (approximately) *

Award Candidate's number of years that s/he has practiced in the profession *

Please use as much space needed to substantiate how this award candidate has demonstrated exceptional professionalism in more than two of the following areas - national/state association activities, community, legislation, administration, public relations, recruitment, mentoring, program development, education, research, publication, and/or therapeutic practice. *

Type your responses here. For more information, please contact us at info@otao.com

Name

FOR MORE INFORMATION:

Occupational Therapy Association of Oregon
Phone: (971)266-4328
Email: info@otao.com