MAXWELL A. POLLACK AWARD NOMINATION FORM

Name of Nominee _______________________________________________________

Address ________________________________________________________________

_________________________________________________________________

City ______________________________ State_________ Zip Code ______________

Telephone _________________ Fax __________________ E-mail _________________

Please attach a two to three page, single-spaced narrative that addresses the following questions (you may include an appendix with additional supporting materials):

1. What policy or practice change did the nominee bring about and why is the contribution significant?
2. Upon what research is the policy or practice change based? (Research is broadly defined to include innovative design; concept building; evaluation; and development and demonstration of new models for practice.)
3. What were the specific contributions of this research to policy and/or practice?
4. What is the impact of this change on the lives of older people?
5. What is the broader impact or potential for replication?

Please submit nominee’s resume or curriculum vita (or equivalent), two letters of endorsement, and the 2-3 page narrative addressing the above questions to: The Maxwell A. Pollack Award Coordinator, c/o The Gerontological Society of America, 1030 15^th Street, NW, Suite 250, Washington, DC 20005-1503.

Nominator (PLEASE PRINT)___________________________________________

Signed ________________________________________________

Telephone ___________________________ Date _________________________

Fax _________________________________ E-mail _______________________

Nominator Address _______________________________________________________

___________________________________________________________

City _________________________ State ________________ Zip Code_____________