Nominator Details
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number (Optional)
Please enter a valid phone number.
Your Role / Position
*
Affiliation / Institution (If Applicable)
Please select what your relationship is to the individual you are nominating:
*
Colleague / Peer
Employer / Manager / Supervisor
Former Colleague / Former Supervisor
Beneficiary / Community Member / Service-User
Friend / Personal Acquaintance
Other (please specify)
Nominee Details
Nominee's Full Name
*
First Name
Last Name
Nominee's Current Affiliation / Employer / Organisation
*
Nominee's Professional Role / Position e.g., Consultant Ophthalmologist, Cataract Surgeon, Optometrist, Programme Director
*
Nominee's Contact Email
*
example@example.com
Nominee Country / Location (or “based in” / “works in”)
*
Nominee's Specialty Area:
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Cataract Surgery
Refractive Surgery
Comprehensive Ophthalmology
Allied Eye-Care Professional
Other
Duration of Sustained Work
Please select one of the following options:
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Less than 1 year
1-3 years
3-5 years
5-10 years
10+ years
ESCRS Membership
Is the Nominee an ESCRS Member? (ESCRS Membership is not required) Please select one of the following:
*
Yes
No
Not Sure
Nominee's Humanitarian Contribution
Summary of Nominee's Background e.g. relevant experience / biography (Optional):
In 500 words or less, please explain why the individual nominated merits the award i.e Description of Work, Contributions, Impact, Period, Scope, Beneficiaries, etc:
*
In 500 words or less, please describe the nominee's key outputs / humanitarian impact (e.g. number of people helped, training delivered, outreach done, measurable outcomes):
*
In 200-300 words, please summarise the nominee’s achievements, who has benefited, and why their humanitarian work is exceptional:
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0/300
Please provide the primary region(s) / population(s) that the nominee has served, priority is given to underserved contexts:
*
Supporting Documents / Evidence (upload) — e.g. Reports, Testimonials, Photos, Case-studies
*
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References / Endorsements
Reference 1: Full Name
First Name
Last Name
Reference 1: Email Address
example@example.com
Reference 1: Relationship to Nominee
Reference 1 Letter of Support
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Reference 2: Full Name
First Name
Last Name
Reference 2: Email Address
example@example.com
Reference 2: Relationship to Nominee
Reference 2 Letter of Support
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Declarations
Permission to contact Nominee and References.
*
I confirm that ESCRS may contact the nominee and listed references regarding this nomination.
Accuracy Confirmation:
*
I confirm that the information provided is accurate to the best of my knowledge.
Conflicts of Interest:
*
I confirm that, to the best of my knowledge, this nomination is free from conflicts of interest, or that any conflicts have been disclosed below.
Data/privacy Consent:
*
I consent to ESCRS processing this information for the purposes of the Humanitarian Award nomination and selection process.
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