Leonard Tow Humanism in Medicine Awards – Final Report Form


Due July 15

Please complete this form following the awards presentation. This information will enable the Foundation to evaluate the program's impact.

Instructions for report completion:

  1. Please print and retain a copy of the completed form before pressing “submit,” as there is no 'save form' feature.
  2. Once you press “submit,” please wait at least two minutes until you are directed to a page that says “Thank you for completing this form.” If you do not reach this page, your submission was not successful; press the back button on your browser and try pressing “submit” again.
  3. If you are unable to submit the form after three attempts, you may fax it to the attention of Harriet Turner at (201) 567-7880.
  4. To the address below, please send via US mail a copy of the awards program, photographs, relevant articles, etc., that cite the 2009 Leonard Tow Humanism in Medicine Awards presented by the Arnold P. Gold Foundation.

School Name

Street Address

City, State, Zip

Contact Person Name

Title & Department

Telephone

Fax Number

E-mail Address

Date of Commencement or Awards Ceremony (YYYY-MM-DD)

Briefly describe the presentation ceremony. Include the name of who presented each award.


Briefly describe the impact that the Leonard Tow Humanism in Medicine Awards presented by the Arnold P. Gold Foundation has had on: the award recipients, the student body, and the medical school faculty.


Do you plan to make any changes to this awards program next year? If so, please describe.


Please let us know of any suggestions you have concerning the award procedures.