Gail Gilewich Practice Award

Nominee Information

Name

First Last

Site & Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone No.

Email Address

SAOT Membership No.

Nominator Information

Nominator 1

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone No.

Email Address

SAOT Membership No.

Nominator 2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone No.

Email Address

SAOT Membership No.

Nominator 3

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone No.

Email Address

SAOT Membership No.

Performance Evidence

Mentoring Relationship

Provide evidence of leadership qualities that are demonstrated in the workplace, including committees at work. Describe how he or she is recognized as an expert and a role model who is easily approached and willing to share knowledge. (60 words)

Leadership/Initiative

Provide evidence of how he or she is a good representative of the profession who strives for increased exposure of occupational therapy in order to advance the profession. (60 words)

Innovation

Describe how he or she demonstrates innovation in program development, assistive devices, etc. (60 words)

Consumer Care

Describe his or her engagement in direct consumer care. (60 words)

Presentations/Publications

Describe his or her involvement in professional sharing through presentations, workshops, publications, etc. (60 words)

Past Awards

List previous awards where he or she was recognized for excellence.