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.

Nomination Deadline:

Completed applications must be received no later than October 15, 2009. You may submit an application online or mail a printed nomination form. 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.

Nominee Information Title Select... Mr. Mrs. Ms. Dr.   Name (First, M.I., Last)                                  Degree   Job Title/Volunteer Role   Address Type (Home, Business, Other) Select... Home Business Other   Address   City State   Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces AA Armed Forces AE Armed Forces AP   ZIP Code   Daytime Phone ( ) -   Evening Phone ( ) -   Email Address   Employer   Brief Description of Role and Responsibilities Nominator Information Title Select... Mr. Mrs. Ms. Dr.   Name (First, M.I., Last)                                  Degree   Job Title/Volunteer Role   Address Type (Home, Business, Other) Select... Home Business Other   Address   City State   Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces AA Armed Forces AE Armed Forces AP   ZIP Code   Daytime Phone ( ) -   Evening Phone ( ) -   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   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. Only complete nominations with the two required letters will be reviewed. Letters must be received or postmarked by October 15, 2009, to be accepted. 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   THANK YOU!