Humanitarian Award Nomination Form

  • WIO Award Nominations

    Thank you for taking the time to submit a nomination of a woman who is deserving of a WIO award.

    Nominee Profile

  • Society or Nominating Body Information

  • (please type name as electronic signature)
  • Description of Service

  • 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.
  • Two page maximum
  • Max. file size: 512 MB.
  • References

    Provide two names and contact information to verify humanitarian service. Provide more references as needed.
  • Reference One

  • Reference Two