Nominee Type
Are you nominating an individual or a team/organisation?
Individual
Team or Organisation
Nominee Name
First Name
Last Name
For teams or organisations, please provide the official organisation or programme name.
Primary Contact Person
Name of the person ESCRS should contact regarding this nomination.
First Name
Last Name
Nominee's Professional Role/Title
e.g., Consultant Ophthalmologist, Cataract Surgeon, Optometrist, Programme Director.
Role/Title
*
Nominee's Specialty / Area of Practice
Please select one of the following:
*
Cataract Surgery
Refractive Surgery
Comprehensive Ophthalmology
Allied Eye-Care Professional
Other
Institution / Affiliation (Optional)
Please select one of the following options:
Hospital
University
NGO
Programme
Country / Region Nominee is Based
Please enter the Country or Region:
*
Nominee's Email Address
*
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
ESCRS Membership
Is the Nominee an ESCRS Member? (ESCRS Membership is not required) Please select one of the following:
*
Yes
No
Not Sure
Nominator Details
Your Name
*
First Name
Last Name
Your Role / Title
*
Institution / Affiliation
Country
*
Email Address
*
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
Relationship to Nominee
This helps the panel understand your perspective.
Please select one of the following options:
*
Colleague
Employer
Partner Organisation
Former Trainee
Professional Peer
Other
Nomination Title
Please provide a clear, descriptive title for the nominee’s humanitarian work:
*
0/100
Brief Summary
In 200-300 words, please summarise the nominee’s achievements, who has benefited, and why this work is exceptional:
*
0/300
Primary Region(s) / Population(s) Served
Please provide the primary region(s) / population(s) that the nominee has served. Priority is given to underserved contexts:
*
Description of the Humanitarian Work
In 1,000 words or less, please describe the initiative or body of work the nominee has undertaken. Include start date, location(s), activities, partners, and how the work addresses unmet eye-care needs.
*
0/1000
Type(s) of Humanitarian Activity
Please select all that apply:
*
High-volume surgery/service delivery
Training and capacity building
Infrastructure/equipment development
Community education and prevention
Innovative outreach/access models
Systems strengthening/long-term programme building
Other
Duration of Sustained Work
Please select one of the following options:
*
Less than 1 year
1-3 years
3-5 years
5-10 years
10+ years
Evaluation Criteria
In 800 words or less, please explain the impact and quality of outcomes achieved:
*
0/800
Key Results / Metrics
Provide headline figures where available (e.g., surgeries delivered, trainees supported) Providing Key Results / Metrics is optional, however you are strongly encouraged to complete this section:
Sustainability and Long-Term Legacy
In 800 words or less, please explain how impact is maintained over time (local ownership, funding, training systems, maintenance plans):
*
0/800
Scalability or Replicability
In 600 words of less, please describe how the model could grow or be adapted to other settings:
*
0/600
Innovation or Problem-Solving Elements
In 500 words or less, please highlight new approaches, technologies, partnerships, or delivery methods:
*
0/500
Governance, Ethics, and Safeguarding
In 600 words or less, please describe patient safety, ethical standards, financial accountability, and safeguarding. ESCRS may conduct due diligence:
*
0/600
Alignment with ESCRS Mission and Knowledge-Sharing
In 600 words or less, please explain how the work supports preventable blindness reduction, equitable access, capacity building, and dissemination of learning:
*
0/600
Registered Non-Profit / Fiscal Sponsor to Receive Funds
Please specify the registered non-profit/fiscal sponsor to receive the funds. Grant funds are disbursed to a registered non-profit or approved fiscal sponsor.
*
Charity Registration Number / Legal Status
Please include registration ID and country.
*
Proposed Use of Funds
In 600 words or less, please explain the proposed use of funds. Funds may support patient services, essential equipment, training, infrastructure, or monitoring/evaluation. Funds may not be used for personal honoraria, salary support, or overheads.
*
0/600
Estimated Budget Breakdown
Please upload a simple budget if available:
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References
Reference 1
*
First Name
Last Name
Role
*
Email
*
example@example.com
Statement (Optional)
Reference 2
*
First Name
Last Name
Role
*
Email
*
example@example.com
Statement (Optional)
Supporting Documents
Upload reports, summaries, or evidence supporting this nomination.
*
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Letters of Support (Optional)
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Photos/Media (Optional)
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Auditable Accounts or Annual Report (If Available)
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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 checkbox label:
*
I confirm that the information provided is accurate to the best of my knowledge.
Conflict of interest checkbox label:
*
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 checkbox label:
*
I consent to ESCRS processing this information for the purposes of the Humanitarian Award nomination and selection process.
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