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Clinical
Service Award
Nomination
Form
Michigan
Speech-Language-Hearing Association requests Exemplary Program nominations.
The
Michigan Speech-Language-Hearing Association's Community and Hospital Service
Committee requests nominations for Speech-Language and/or Hearing Programs to be
recognized. A program (which
includes at least one MSHA member) may be nominated by anyone who feels it is
deserving of statewide recognition. Please
complete this form and return it to the MSHA office.
The Community & Hospital Service committee will review all
nominations, request additional documentation as needed and may conduct an
on-site visit in making our final determination. See Guidelines page for
more information. PLEASE TYPE OR PRINT
LEGIBLY. Thank you!
Program Name:
Facility:
Address:
Phone:(
)
Fax:( ) E-Mail:
Primary
person(s) providing services for this program and their title/position:
Any
other person(s) to be included in this nomination:
Identify
MSHA members involved in this program:
Date
of program inception:
List
of program credentials, certification and accreditation (e.g. JCAHO, CARF, AOA,
PSB):
On
an additional sheet of paper provide a brief description of population served,
disability area and age. Please list 5 features of this program which make it
exceptional. Attach any additional information such as brochures which may
assist in the selection process.
Nominated By:
Address:
Phone
Work:(
)
Home:(
)
Fax:( ) E-Mail:
Administrator responsible for this program:
Address:
Phone
Work:(
)
Home:(
)
Fax:(
)
E-Mail:
Return
to:
MICHIGAN SPEECH-LANGUAGE-HEARING ASSOCIATION
790 W. Lake Lansing Rd., Suite 500-A, East Lansing, MI 48823
(517) 332-5691 FAX: (517) 332-5870
DEADLINE
FOR NOMINATIONS: September 1st
