Award Nomination Form - IUPUI Alumni Relations

Award Nomination FormThe Indiana University School of Medicine Alumni Association (IUSMAA) annually recognizes alumni andfaculty who have brought distinction upon themselves, their profession, and the IU School of Medicine in threeseparate categories: the Glenn W. Irwin, Jr., M.D. Distinguished Faculty Award; the Early Career AchievementAward; and the highest distinction awarded by the Alumni Association, the Distinguished Alumni Award. Forthe purpose of these awards, an alumnus is defined as any graduate or former trainee (resident, fellow, orintern) from either the professional or graduate divisions of the School.Award recipients will be recognized during the Alumni Weekend 2011 opening reception on Friday, May 20,2011, at University Place Hotel beginning at 5:45 p.m.Glenn W. Irwin, Jr, M.D. Distinguished Faculty AwardFirst presented in 1987 by the IUSMAA, this award recognizes faculty with outstanding service to the IU Schoolof Medicine through dedication to students, colleagues, research, or the medical profession. Current orformer faculty of the IU School of Medicine are eligible for this award.Early Career Achievement AwardIn 2006 the IUSMAA established this annual recognition for outstanding accomplishments in medicine and/orservice to the School by medical alumni who have graduated within 15 years of the award presentation. Allgraduates and former trainees who departed IUSM within the past 15 years are eligible.Distinguished Medical Alumni AwardSince 1970, 48 alumni from the IU School of Medicine were bestowed the honor of Distinguished Alumnus.Awarded annually, this award recognizes outstanding alumni of the School who have brought honor to theiralma mater by distinguishing themselves either professionally or by giving extraordinary service to the School.IU School of Medicine graduates and former trainees are eligible for this award.New Deadline for 2011 nominations – Friday, February 25, 2011A listing of the previous Medical Alumni Association Award recipients can be found online atwww.alumni.iupui.edu/medicine/awards.htm

How to nominate an alumnus or faculty memberA nomination is considered complete when the following materials are submitted:The IU School of Medicine Alumni Association Award Cover Page. A letter of nomination from the nominator detailing why this nominee should be considered forthe selected award; The nominee’s vitae; Any additional supporting documents the nominator deems important to demonstrate thisnominee’s credentials for the selected award.Since these awards recognize alumni who have brought honor to their alma mater throughdistinguished career service, achievement, and/or extraordinary service to the IU School of Medicine,please include specific examples of the nominee’s achievements, including any service by the nomineeon boards, committees, and organizations at the department, school, campus, university, state, ornational level.Nominations will be accepted until Friday, February 25, 2011. Each nominee requires a separate form.Questions? Contact Alumni Director Jayme Little at (317) 274-1345, (866) 267-3104, or emailjtlittle@iupui.edu.Nominations are accepted by mail, fax, or email to:IUPUI Alumni Relations – IUSM Alumni Awardsc/o Jayme Little, Director850 West Michigan Street, Ste.241Indianapolis, IN 46202Fax: (317) 274-5064 Email: IUSMalum@iupui.eduA listing of the previous Medical Alumni Association Award recipients can be found online atwww.alumni.iupui.edu/medicine/awards.htmThe Indiana University School of Medicine Alumni Association is a dues supported constituency group of the IUAlumni Association. Join online today at http://alumni.iu.edu/memembership. Convenient payroll deductionis available for faculty and staff who work for Indiana University.Membership status in the IUAA does not affect the outcome of the awards process.

IU School of Medicine Alumni Association Award Cover PageThis form is intended to serve as a cover page for all awards.For which award are you nominating this alumnus/faculty?Glenn W. Irwin, Jr., M.D. Distinguished Faculty AwardEarly Career Achievement AwardDistinguished Alumni AwardNominee InformationFirst Name Last Name SpecialtyIU Degree Year Earned Other Degree(s) Year(s) EarnedHome Street Address City State ZipPlace of EmploymentBusiness Street Address City State ZipEmail Address Home Phone Secondary PhoneNominator InformationFirst NameLast NameBusiness NameBusiness TitleBusiness Street Address City State ZipContact Phone Number E-mail address Are you an IU alumnus?YesNO