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Lane Adams Quality of Life Award Nomination Form

This form is to be completed by the nominator and will be considered in the selection of the finalists for the Lane Adams Quality of Life Award. Once the Selection Committee has chosen the finalists, additional information may be needed.

Nominators are encouraged to review the four criteria outlined and illustrated under "Who is Eligible for the Lane Adams Quality of Life Award?" section of this website.
1) Excellence in direct caregiving
2) Demonstrated record of performance that exceeds the expectations for a person in that role or job
3) Role Model for colleagues
4) Demonstrated record of innovation / collaboration in enhancing quality of life for cancer patients and their families.

The nomination "statement" should give specific examples of these four characteristics of the nominee's work and accomplishments.

Nomination Deadline:

Completed applications must be received no later than November 1, 2011. You may submit an application online or mail a printed nomination form [Word, 34KB]. If you choose to send your application form via hard copy, please mail it to:

American Cancer Society
ATTN: Ann Robinson
Office of the Chief Medical Officer
Department of Research and Cancer Control Science
250 Williams Street, NW
Suite 600
Atlanta, GA 30303-1002

Should you have any question regarding the awards or nomination process, please contact Ann Robinson at 404-329-7720, or via email at ann.robinson@cancer.org.

Only complete nominations with the two required letters will be reviewed. All fields are required.

* Required Fields

NOMINEE INFORMATION

Title:

First Name*:

M.I.:

Last Name*:

Degree:

Job Title/Volunteer Role*:

Address Type*:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip Code*:

Primary Phone (Please enter only digits)*:

Extension:

Type*:

Secondary Phone (Please enter only digits):

Extension:

Type:

Email Address*:

Employer*:

Brief Description of Role and Responsibilities*:

NOMINATOR INFORMATION

Title:

First Name*:

M.I.:

Last Name*:

Degree:

Job Title/Volunteer Role*:

Address Type*:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip Code*:

Primary Phone (Please enter only digits)*:

Extension:

Type*:

Secondary Phone (Please enter only digits):

Extension:

Type:

Email Address*:

Employer*:

Type and Length of Association with Nominee*:

EXAMPLES OF LEADERSHIP, INNOVATION AND EXCELLENCE

Finalists will be selected on the basis of Leadership, Innovation and Excellence. Please include a statement in the box below, not to exceed 7500 characters, including spaces, which addresses the following question:

What sets the nominee apart from their colleagues with regard to cancer caregiving?

Share examples of how this person has exceeded the expectations of their job duties to demonstrate consistent excellence or innovative approaches in cancer care.

Please click here to view examples of leadership, innovation and excellence

Comments*:

LETTERS OF SUPPORT REQUIRED

To complete this nomination process, please send (under separate cover) two letters of support for this nominee. Letters should offer insight and/or examples of ways in which nominee provides consistent, outstanding, compassionate care to cancer patients and their families.

One letter must be from a patient or family member, and one from a colleague/ co-worker. You may send two from each category if available. These letters are necessary for this nomination to go forward.

I have at least one patient or family member letter.
I have at least one colleague/co-worker letter.

Fax, email, or mail letters to: (Be sure to include names of Nominator and Nominee)

American Cancer Society

ATTN: Ann Robinson

Office of the Chief Medical Officer

Department of Research and Cancer Control Science

250 Williams Street, NW

Suite 600

Atlanta, GA 30303-1002

Fax: 404-329-7530

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Lane Adams Quality of Life Award Nomination Form

Fax, email, or mail letters to: (Be sure to include names of Nominator and Nominee)

THANK YOU