WIO AWARD NOMINATIONS

Thank you for taking the time to submit a nomination of a woman who is deserving of a WIO award.

Nominee Profile

Nominee Name*

Email*

Phone*

Address

Age of Nominee

Does the nominee know she is being nominated?

Yes
No

Is the nominee a US citizen?

Yes
No

If not a US citizen, is nominee a permanent resident?

Yes
No

Is the nominee a member of WIO?

Yes
No

Society or Nominating Body Information

Name*

First Last

Email*

Phone

Society Name or Nominating Body

Address

Street Address City State / Province / Region ZIP / Postal Code Country

E-signature*

(please type name as electronic signature)

Description of Service

Describe in detail the nature of the public humanitarian service provided by the nominee.*

Include need for this service, consistency of service, length, consistency of the service and the scope of impact & estimate the number of people served.

What activity or initiative (s) has the nominee accomplished that merits this nomination?

What was their role in the initiative? (personal service/volunteerism, initiator/founder, educator of medical professionals, Educator of patients?

In what capacity did the nominee serve above and beyond the usual volunteer commitment?

How did it entail personal sacrifice on the part of the Ophthalmologist?

What did the nominee demonstrate in terms of collaboration with host country and local ophthalmologist?*

What patient population and geographic area are the primary targets of the nominee’s efforts? Who are the patients that the individual nominated serves?

Explain how they benefit from the care provided by the nominee. and describe the impact on this population due to the nominee’s efforts.

Describe the impact on this population due to the nominee’s efforts.

To the best of your knowledge are the nominee’s principles consistent with the Code of Ethics?*

How does the individual embody the following values of the medical profession? (leadership, excellence, integrity and ethical behavior).

Has the nominee received any other awards for this type of humanitarian service?

If so, list the award and dates received.

Provide a brief biographical summary of your nominee or attach CV.

Two page maximum

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Max. file size: 512 MB.

References

Provide two names and contact information to verify humanitarian service. Provide more references as needed.

Reference One

Name of Reference #1

First Last

Title

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference Two

Name of Reference #2

First Last

Title

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

WIO AWARD NOMINATIONS

WIO Award Nominations

Nominee Profile

Society or Nominating Body Information

Description of Service

References

Reference One

Reference Two

Enhancing & improving the professional environment for women ophthalmologists

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