Leonard Tow Humanism in Medicine Awards – Interim Report Form

Due: March 31, 2017 (or 3 weeks before presentation date)
Instructions for report completion:
  1. Please print and retain a copy of the completed form before pressing “submit,” as there is no ‘save form’ feature.
  2. Once you press “send,” please scroll down to the very bottom of the page to view a message confirming that your submission was successful.  If a “validation error” occurs, that means you have failed to complete one or more required entries.
  3. If you are unable to submit the form after two attempts, you may fax it to the attention of Ian Finisterre at (201) 567-7880.

Fields marked with an * are required

Describe in detail the selection process.
How were nominations solicited?
Does it differ for student and faculty nominations?
How many rounds to your nomination process?
What percentage of students/faculty participated?
How did selection take place? Who is involved in the selection process? (If a committee is used, please list members.)
Is the process the same for student and faculty selection?

print names as they should appear on certificate