OSHP Humanitarian Award
To recognize the health-system pharmacist who has made outstanding and admirable contributions to his/her community and society over the past year.
Nominee Information
Nominee Name
First Name
Last Name
Nominee Email Address
*
example@example.com
Nominee Phone Number
*
-
Area Code
Phone Number
Nominee significant contributions to humanitarian effort.
Please describe the nominee’s involvement in an underserved population. Please include years involved and hours volunteered. Underserved involvement should be humanitarian involvement in medicine and can include (but is not limited to) free clinics, medical mission trip(s), etc. This should not include efforts completed as part of one’s paid position (i.e. being paid to work in an underserved clinic).
Please provide evidence of outcomes related to humanitarian efforts (ex: how many patients were reached as part of patient outreach, how many patients were referred to consult or social services, etc.).
Nominee significant community engagement (if more to be added than what appears on CV)
Additional Significant Information
Nominator Information
Nominator Name
*
First Name
Last Name
Nominator Employer
*
Nominator Phone Number
*
-
Area Code
Phone Number
Nominator Email Address
*
example@example.com
By checking below, I hereby: Attest that all information I have provided in conjunction with this application is true and completed by myself as the nominator. Attest that this individual is of upmost ethical and professional standing. Acknowledge and agree that if during the application process, I make any false or misleading statements—including material omission—that this may be considered grounds for removal of the application from award consideration
*
I have read and agree with the above statement
Attachments
Nominee's CV (required)
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Additional Evidence #1- Limit attachment to no more than 2 pages.
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