The Fogarty Prize
Nomination Form
1. Nominee Information (up to three per technology )
Name
First Name
Last Name
Title/Position
Institution/Organization/Company
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website (if applicable)
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Second Nominee Information (leave blank if not applicable)
Name
First Name
Last Name
Title/Position
Institution/Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website (if applicable)
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Third Nominee (leave blank if not applicable)
Name
First Name
Last Name
Title/Position
Institution/Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website (if applicable)
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2. Nominator Information
Name
First Name
Last Name
Title/Position
Institution/Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Nominee(s)
3. Nomination Details
Name of Technology
Brief Description of Technology (250 words )
0/275
Clinical Impact of Technology (500 words)
0/525
4. Supporting Information
Detailed Description of the Technology (1000 words)
Describe the problem this technology addresses, explain how it works, provide evidence of clinical impact and any validation studies.
0/1025
Innovative Aspects (500 words)
Highlight unique features/advantages of the technology. Explain how the technology advances the field.
0/525
Implementation and Commercialization (500 words)
Describe the steps taken towards commercialization. Detail any partnerships, funding, or market adoption.
0/525
Testimonials - Patient or Family (if applicable - 250 words)
Provide a testimonial from a patient or family member affected by the technology
0/275
Testimonials - Physician (if applicable - 250 words)
0/275
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5. Additional Materials
Please attach the following documents
Nominee(s) CV or resume
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Letter of recommendation (minimum of two, maximum of three)
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Relevant publications or patents
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Additional supporting documentation (clinical trial data, market analysis, other)
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6. Declaration
I hereby declare that all information provided in this nomination form is accurate and complete to the best of my knowledge. I understand that the information submitted will be used for the purpose of evaluating the nominee for the Fogarty Prize.
Signature
Submission Instructions
Please submit the completed nomination form and all supporting materials by July 31, 2025.
Questions?
Contact Allie Gregorian: allie@fogartyinnovation.org
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