Leonard Tow Humanism in Medicine Awards – Final Report Form

Due: July 15, 2019 (or no later than 30 days  after award presentation)

Please complete this form following the awards presentation. This information will enable the Foundation to evaluate the program’s impact.

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 “submit,” please wait at least two minutes until you are directed to a page that says “Thank you for completing this form.” If you do not reach this page, your submission was not successful; press the back button on your browser and try pressing “submit” again.
  3. If you are unable to submit the form after three attempts, you may fax it to the attention of Gwen Tundermann at (201) 567-7880.
  4. Send physical media, a copy of the program, photographs and other printed materials to the following address: Gwen Tundermann | The Arnold P. Gold Foundation | 619 Palisade Ave | Englewood Cliffs, NJ 07632

Include any relevant materials below: