WSHA Awards Nomination Form
Help WSHA recognize excellence by submitting a colleague for an award!
The awards process is the single most important means that WSHA has for recognizing those who have made significant contributions to speech-language pathology and audiology in Wisconsin. Please fill out the form below to submit your nomination. Questions may be directed to the WSHA office by emailing WSHA@badgerbay.co.
Award Proposed:
Honors of the Association Award
WSHA Salutes Outstanding Service Award
WSHA Lifetime Achievement Award
DiCarlo Clinical Achievement Award
Frank R. Kleffner Career Award
Rolland J. VanHattum Award
Audiologist of the Year Award
Speech-Language Pathologist of the Year Award
WSHA Student Mentor Award
WSHA Student Leadership Award
Name of Nominee
First Name
Last Name
Address of Nominee
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Nominee
-
Area Code
Phone Number
Email of Nominee
example@example.com
Current Position/Affiliation of Nominee
Name of Nominator
First Name
Last Name
Email of Nominator
example@example.com
Current Position/Affiliation of Nominator
Is this an individual or group nomination?
Individual
Group
BASIS FOR NOMINATION - Please be very specific and provide detailed information as to how the nominee meets the criteria. Supporting documentation can also be submitted.
Additional documentation
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Additional documentation
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