Gary Kielhofner Emerging Leader Award

GARY KIELHOFNER EMERGING LEADER AWARD

Description and Purpose  To recognize an occupational therapy practitioner (clinician, educator, or researcher) who has demonstrated emerging leadership and/or extraordinary service early in his or her occupational therapy career.  To acknowledge an occupational therapist or occupational therapy assistant who has developed the leadership capacity to serve the profession, professional associations, or the community; and whose efforts and leadership skills have contributed to moving the profession closer to achieving the goals set forth in the Centennial Vision.  To provide incentive for practitioners to model leadership development and enablement of others within the profession.

Minimal Requirements 1. The nominee(s) shall be an occupational therapist or an occupational therapy assistant member in good standing of the Association at the time of the nomination and presentation of the award and has been an Association member for no less than three consecutive years upon nomination and is not more than five years from formal graduation. 2. The nominee(s) shall exemplify extraordinary leadership in one or more of the following categories:  Development of an emerging practice area (i.e., innovative models of community-based OT practice, embracing new technologies in treatment provision, health promotion and wellness, etc.),  Advocacy (i.e., regulatory, legislative, policy and reimbursement issues; advocacy for a client need within the community, promotion of occupational therapy, etc.),  Service to the professional association on a state and/or national level,  Demonstrated contribution to the Centennial Vision,  Significant contribution to the body of occupational therapy knowledge, or  Notable impact on the profession by building the leadership capacity of others ( i.e. instilling the desire for leadership in others or growing leadership in their community), and/or volunteerism which has met a significant need while inspiring others

Specific Information Regarding Award 1. The awardee shall be presented with the Gary Kielhofner Emerging Leader Award. 2. One award recipient will be recognized per year.

INSTRUCTIONS: Please complete this form for each nomination. All information must be typed. Note: If notification is to be sent to a university address, please be sure to include as much detailed information on the address as possible, (i.e., room, division, building, mail stop, campus box). Please be aware that notifications may be sent during typical university breaks.

1. NOMINEE Name & Credentials Title Address City/State/Zip Telephone (Office) Telephone (Home) E-mail AOTA Member ID # Expiration Date Number of years activity in occupational therapy:

Title Address City/State/Zip Telephone (Office) Telephone (Home) E-mail (Office) E-mail (Home) AOTA Member ID # Expiration Date

3. SEVEN-WORD STATEMENT: This statement needs to directly reflect the content of the Narrative and capture the significant impact of the individual’s contributions. Please note that this is the statement that will appear on the actual award. The Volunteer Leadership Development Committee reserves the right to modify statements.

4. NARRATIVE:  Submit a narrative in the box below that describes how the individual’s significant contributions justify his or her receipt of this award. Please refer to the purpose and criteria of the specific award in your discussion of his or her eligibility.  The purpose of the narrative is to augment or explain—not repeat—the information included in section 5: Relevant Experience.  Do not exceed eight (8) double-spaced pages using 12-point font.  Please do NOT send letters of support as they are not considered in the review process.  The narrative will be included in the scoring process.

5. RELEVANT EXPERIENCE: SELECTION CRITERIA All information must be typed and outlined according to the following selection criteria. Space will expand to accommodate response. Additional rows may be added.

EDUCATION Date of Degree/Area Institution Graduation (MM/DD/YYYY)

PAID PROFESSIONAL WORK EXPERIENCE Dates Post/Title Institution/Facility

WRITTEN COMMUNICATIONS

 Please only include work that is published.

 List funded grants only, and please include the funding amount and role (e.g. principal investigator - PI)

 You may add as many rows as needed in each category to give a complete picture of the nominee’s written work.

 Include date, title, and publisher (or granting agency), for each type of publication for each example

Book (authored), published assessments Date Title Publisher

Chapter in a book, self-study series Date Title Publisher

Book (edited) or article in a professional journal Date Title Publisher

Grant proposal funded (PI) over $5,000 Date Title Publisher

Grant proposal funded (PI) $5,000 or below Date Title Publisher

Grant proposal funded (co-PI) any amount Date Title Publisher

Team member on a grant (team made up of more than 2 members) Date Title Publisher

Manual, monograph, and/or AOTA Official Document Date Title Publisher

Book Review (professional) or abstract (published) Date Title Publisher

Articles – OT Practice, SIS Quarterly, and/or other trade magazines Date Title Publisher

Miscellaneous – pamphlet, informational article, newsletter, newspaper article, etc. Date Title Publisher

Miscellaneous advocacy article, letter to editor, legislator, etc. Date Title Publisher

ORAL COMMUNICATIONS  Please include first offering of presentation only.  Only include presentation that are not part of the nominee’s job  If co-presenting with others, please identify the specific amount of nominee’s speaking time.  Include only completed presentations.  You may add as many rows as needed in each category to give a complete picture of the nominee’s oral work.  Include date (month and year), length of nominee’s speaking time, title, location, and type of presentation (e.g. workshop, seminar, in-service, keynote), for each type of presentation for each example

Two or more days Date of Event Actual Length Title Location Type of of Presentation Presentation

1 day (over 4 hours)

Date of Event Actual Length Title Location Type of of Presentation Presentation

Half-day (2-4 hours) Date of Event Actual Length Title Location Type of of Presentation Presentation

Presentation less than 2 hours (Radio/TV presentation-interview, poster session) Date of Event Actual Length Title Location Type of of Presentation Presentation

Panel member, in-service presentation Date of Event Actual Length Title Location Type of of Presentation Presentation

AUDIOVISUAL & WEB-RELATED COMMUNICATIONS

 Please include first offering only.  Only include materials that are not part of the nominee’s job  Include only completed materials  You may add as many rows as needed in each category to give a complete picture of the nominee’s audiovisuals or web-related materials  Include date, title, type of A/V or web materials produced, and the distribution source for each type of A/V or web material for each example

Videos, movies, intervention based software, apps (not part of job responsibilities) Date Title & Procurement Type of A/V Web Materials Distribution Source Information Produced

Webinars, podcasts (not part of job responsibilities) Date Title & Procurement Type of A/V Web Materials Distribution Source Information Produced

Development of web-related publications, social media e.g., blog, website, etc. (not part of job responsibilities) Date Title & Procurement Type of A/V Web Materials Distribution Source Information Produced

LEADERSHIP PARTICIPATION & ENGAGEMENT

 List all volunteer leadership experiences not part of the nominee’s job  You may add as many rows as needed in each category to give a complete picture of the nominee’s volunteer service  Include the title of position, name of organization, dates of service, and total years/months

Volunteer Service to AOTA

Board Officer (President, Vice President, Secretary, Treasurer) Position Organization Dates of Service Total Years/Months

Board Member Position Organization Dates of Service Total Years/Months

Official of the RA (Speaker, Vice Speaker, Recorder) Position Organization Dates of Service Total Years/Months

RA Representative Position Organization Dates of Service Total Years/Months

Committee/Commission Chair (>5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee/Commission Member (>5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee/Commission Chair (<5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee/Commission Member (<5 hrs/month of work) Awards Nomination Information  Copyright 2014 The American Occupational Therapy Association, Inc. All rights reserved. 6 GARY KIELHOFNER EMERGING LEADER AWARD

Position Organization Dates of Service Total Years/Months

Organizational Advisors (e.g., WFOT, AOTPAC, ASAP, ASD, Academic Leadership Council) Position Organization Dates of Service Total Years/Months

Other Volunteer (e.g., conference proposal reviewer, conference volunteer, AJOT/OT Practice article reviewer) Position Organization Dates of Service Total Years/Months

Volunteer Service to Other OT Organizations (e.g., AOTF, ACOTE, NBCOT, WFOT, State Associations, Licensure Boards)

Officer (President, Vice President, Secretary, Treasurer) Position Organization Dates of Service Total Years/Months

Committee Chair (>5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee Member (>5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee Chair (<5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Committee Member (<5 hrs/month of work) Position Organization Dates of Service Total Years/Months

Volunteer Other Position Organization Dates of Service Total Years/Months

Volunteer Service to Health related organizations (e.g., Arthritis Foundation, Autism Speaks)

Volunteer Other Position Organization Dates of Service Total Years/Months Awards Nomination Information  Copyright 2014 The American Occupational Therapy Association, Inc. All rights reserved. 8 GARY KIELHOFNER EMERGING LEADER AWARD

Volunteer Service to Non-OT and/or Non- Health Related Organizations (e.g., schools, religious, civic, community)

Volunteer Other Position Organization Dates of Service Total Years/Months

DEVELOPMENT OF EMERGING PRACTICE AREAS (e.g., innovative models of community based practice, use of new technologies in treatment provision, health promotion and wellness,)

Practice Area Population Date Location

ADVOCACY ( e.g., regulatory issues, legislative advocacy, reimbursement for services, policy development and implementation, client advocacy, promotion of occupational therapy)

Advocacy Activity Local/State/National Date

BUILDING LEADERSHIP CAPACITY IN OTHERS (e.g., helping others develop leadership potential, volunteerism that meets a significant need and achieves a common goal)

Leadership Activity Person Impacted Date

6. VERIFICATION AND PHOTO  All nominations must include a signed verification form and photo.  Include current credentials and name as desired for publication.  Include pronunciation of name and preferred method for alphabetizing multiple last names for use by announcer during the Awards Ceremony.  Be sure that photo is in digital jpeg format and in “print” resolution. (Web resolution cannot be accepted).  Head shots in professional dress are most desirable for publication. If this is not possible, crop unwanted background prior to submission.

7. SUBMISSION GUIDELINES

 Questions regarding this award can be directed to [email protected] prior to the nomination deadline of September 23, 2014 at 11:59 PM.

 Submit this document in MS Word format only. No PDFs will be accepted. Do not submit the Narrative as a separate attachment but place it in the text box noted above in Section 4. Submitted materials must follow the required format otherwise the nomination will not be scored. Please do not include a curriculum vitae (CV).

 Submissions will only be accepted electronically. Please send the completed nomination form, verification form, and photo no later than the deadline of September 23, 2014 at 11:59 PM to [email protected].

Statement of Authenticity:

I have read the instructions and clarifying information provided me in this document and attest to the accuracy of the information I have included in this nomination form and the accompanying narrative.

Signature of Nominator Date

NOTE: My electronic (typed) signature on this document constitutes my legal signature in accordance with 21 CFR Part 11: Electronic Records; Electronic Signatures Act.