Leonard Tow Humanism in Medicine Awards – Interim Report Form

Due: March 15, 2021 (or sixty (60) days before presentation date)
Instructions for report completion:
  1. Complete all required fields. Incomplete submissions (without proper bios and headshots) will not be accepted. Please note that bios and headshots are required for internal processing of the award and will not be shared publicly.
  2. Please print and retain a copy of the completed form before pressing “submit,” as there is no ‘save form’ feature.
  3. Once you press “send,” you should receive a success message indicating that your form was successfully submitted.
  4. In order to complete your form you will need:
    1. A brief biosketch of each awardee including the awardee’s humanistic qualifications
    2. A headshot photo of each awardee

Fields marked with an * are required

It is expected that this award is given at the main graduation award ceremony or commencement.

We will be conducting a survey later this year to better understand the nomination and selection process.

print names as they should appear on certificate

Permanant/Home Address

Permanant/Home Address

We will be sending out a survey to better understand the nomination process later in the year.