APA 2021 Awards Common Nominations Form Question Title * 1. Please select which award you are applying or nominating someone else for: Health Care Delivery Award Miller-Sarkin Award Public Policy and Advocacy Award Research Award Teaching Junior Faculty Award Teaching Mid-Career Award Teaching Program Award OK Contact Information for the Nominee(You may self-nominate or nominate someone else.) OK Question Title * 2. Full Name of Nominee (with designations) OK Question Title * 3. Institution OK Question Title * 4. Title OK Question Title * 5. Does this person (or you, if self-nominating) identify as a URM?*The APA defines URM using the AAMC's 2004 definition: "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population," which includes the following racial and ethnic groups: Black or African American, Hispanic/Latino, Native American or Alaskan Native, Native Hawaiian and other Pacific Islander. Yes No OK Question Title * 6. Address 1 OK Question Title * 7. Address 2 OK Question Title * 8. City, State Zip OK Question Title * 9. Email: OK Question Title * 10. Phone Number: OK Question Title * 11. Please upload the nominee’s CV. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload the nominee’s CV. OK Please upload two nomination letters below (one to two pages each). The letters should highlight the nominee’s accomplishments and explain why the nominee is deserving of the award. The letters can be written by you, a supervisor and/or a colleague. OK Question Title * 12. Please upload letter of nomination #1. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload letter of nomination #1. OK Question Title * 13. Please upload letter of nomination #2. DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload letter of nomination #2. OK Question Title * 14. Please upload letter of nomination #3 (only required for Miller-Sarkin). DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload letter of nomination #3 (only required for Miller-Sarkin). OK Question Title * 15. Please upload letter of nomination #4 (only required for Miller-Sarkin). DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload letter of nomination #4 (only required for Miller-Sarkin). OK Question Title * 16. Please upload statement from nominee (only required for Miller-Sarkin, please refer to website for details) DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload statement from nominee (only required for Miller-Sarkin, please refer to website for details) OK Question Title * 17. The Teaching Program, Teaching Junior Faculty, and the Teaching Mid-Career Faculty awards require additional application materials. Please click on the links above to view the additional requirements. Please upload the additional required application materials here. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File The Teaching Program, Teaching Junior Faculty, and the Teaching Mid-Career Faculty awards require additional application materials. Please click on the links above to view the additional requirements. Please upload the additional required application materials here. OK Only fill out this section if you are nominating a colleague. OK Question Title * 18. Full Name of Nominator if Different from Nominee (with designations): OK Question Title * 19. Institution: OK Question Title * 20. Title: OK Question Title * 21. Address 1: OK Question Title * 22. Address 2: OK Question Title * 23. CIty, State Zip OK Question Title * 24. Email: OK Question Title * 25. Phone Number: OK THANK YOU FOR YOUR TIME. CLICK HERE TO SUBMIT.