George L. Eckert Jr., DO, Mentor of the Year Award

Ohio Osteopathic Association
George L. Eckert Jr., DO, Mentor of the Year Award

NOMINATION FORM

I would like to nominate:

Physician's Name:
Practice Name:
Practice Address:
City, State and Zip:
Phone:
Fax:
Email Address:
Specialty:
Hospital Affiliation:

Please answer the following questions:

1. What has the mentor done that distinguishes him/her from other mentors in helping to develop your medical skills and ability to interact with patients?

2. How does this mentor inspire professionalism and teamwork in his/her practice?

3. How has this mentor served as an advocate and leader in the medical community, and specifically contributed to the practice of osteopathic medicine, if he/she is an osteopathic physician?

4. How has this mentor inspired you personally as your advisor and a role model?

5. Share one or two favorite mentor story that illustrate why this mentor goes the extra mile.

Nomination submitted by:
Name:
Mailing Address:
Phone:
Email Address:
Level of Training:
Medical School Attending/Attended:
Hospital Training Site:
DME/Program Director or CORE Assistant Dean:
Residency/Fellowship Specialty:

- denotes required fields