Pioneer Award Nomination Form

Complete the nomination form below. Attach up to 15 pages of supporting statements or documents. On supporting documents, summarize the nominee’s contributions to innovative and creative hospital leadership. Include supplemental information or documents that address activities and accomplishments that support the individual’s nomination. All fields are required.

Submit form by 5 p.m., Friday, Sept. 29, 2023. Nominations received after this date will not be considered.

Nominee's Name:(Required)

Position:

Hospital/Health Care System:

Address:

City:

State:

ZIP:

Nominee's name as it should appear on award:

On a separate sheet, summarize the nominee’s professional achievements and contributions to the health care industry. Note involvement in THA and/or other industry trade associations or professional groups. Attach a complete curriculum vitae. Also include individual statements and/or supplemental information or documents addressing activities and accomplishments of the nominee in such fields as health care administration, patient care, health care research or education, and participation in community, civic or pertinent religious activities.

Attach below any supporting documentation or statements. On supporting documents, summarize the nominee’s contributions to innovative and creative hospital leadership. Include supplemental information or documents that address activities and accomplishments that support the individual’s nomination.

Attachment:

Drop files here or

Max. file size: 50 MB.

Submitted by:(Required)

Position:

Hospital/Health Care System:

Address:

City:

State:

ZIP:

Phone:

Fax:

Email(Required)

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