(please type name as electronic signature)
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 was their role in the initiative? (personal service/volunteerism, initiator/founder, educator of medical professionals, Educator of patients?
How did it entail personal sacrifice on the part of the 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?
Describe the impact on this population due to the nominee’s efforts.
How does the individual embody the following values of the medical profession? (leadership, excellence, integrity and ethical behavior).
If so, list the award and dates received.