Outstanding Clinician Award Nomination Form

The MSHA Health Care Committee requests nominations for Speech, Language, and/or Hearing Clinicians to be recognized. Nominations may come from anyone who feels the clinician is deserving of statewide recognition. Additional information may be requested via email (info@mislha.org) prior to determining an individual’s eligibility. The Health Care Committee will review all nominations and may conduct an interview with eligible nominees.

Eligibility and Guidelines:
It is the intent of the Health Care Committee’s Outstanding Clinician Award to accomplish the following:

Give visible recognition to outstanding speech, language, and hearing clinicians working in health care in the state of Michigan.
Motivate individuals to provide excellent clinical services.
Showcase these clinicians to promote public awareness of the services delivered by our professions.
This award is an annual event wherein recognition is given to one or more clinicians. Extensive coverage will be given to the individuals(s) at the MSHA Conference, in MSHA publications and on the MSHA website. A media press release will be distribute

For purposes of participation in this project, a health care-based clinician is defined as follows:

Any provision of service to the speech, language and hearing impaired in a clinical setting. This can include a hospital-based department, a sub-unit of a department, an itinerant program, a clinic, or private practice setting.

Note: This award is not open to public school-based clinicians. Please contact MSHA via email (info@mislha.org) regarding awards recognizing school-based programs and clinicians.

Eligibility criteria:
1. The clinician is a current MSHA member and has been for at least 3 years.
2. The clinician is currently practicing in Michigan and has a State of Michigan License.
3. The clinician has been practicing as a Speech Language Pathologist for at least 5 years.
4. The Clinician has current ASHA CCCs.

The procedure for participating is as follows: Nominations may be made by anyone - client, caregiver, colleague, director. Nominations must be submitted on the reverse of this form. Nominations will be reviewed by the Health Care Committee.

Required documents to accompany nomination form:

Three letters of recommendation, two should come from co-workers or colleagues.
Copy of the clinicians resume or CV, which should list, among other things, information on:
- Experience working with or supervising students and/or clinical fellows.
- Mentorship provided to other professionals/provision of training outside of the field.
- Community outreach activities.
- Membership in other states, or national organizations (not including ASHA).
- Service on MSHA Committees or those of other professional organizations.
- Offered continuing education/peer reviewed presentations.
- Specialty recognition achieved (e.g., Board Certification from ASHA or awards, excluding continuing education awards).
- Clinical projects/ publications

Additional information may be requested prior to determining an individual’s eligibility. The Health Care Committee will review all nominations and may conduct an interview with eligible nominees.

First Name *

Last Name *

Email *

Nominee's Information

Clinician's Name: *

Facility: *

Current Michigan License: *

Is the clinician's ASHA C's current? *

Yes

Is the candidate’s MSHA membership current: *

Yes

MSHA Member since: *

Work Phone: *

Cell or Home Phone: *

Address: *

Email Address: *

Nominator's Information:

Nominated by: *

Address: *

Work Phone: *

Cell or Home Phone: *

When would be the best time to contact you if needed? *

Email Address: *

Please use the upload buttons below to upload the following required documents:

Three letters of recommendation, two should come from co-workers or colleagues.
Copy of the clinician’s resume or CV, which should list, among other things, information on:
- Supervision of students and/or clinical fellows.
- Mentorship provided to other professionals/provision of training outside of the field.
- Community outreach activities.
- Membership in other states, or national organizations (not including ASHA).
- Service on MSHA Committees or those of other professional organizations.
- Offered continuing education/peer reviewed presentations.
- Specialty recognition achieved (e.g., Board Certification from ASHA or awards, excluding continuing education awards).
- Clinical projects/ publications.

Letter of Recommendation #1 *

Letter of Recommendation #2 *

Letter of Recommendation #3 *

Clinicians CV or Resume *

Michigan Speech Language Hearing Association