ACCE Robert L Morris Humanitarian Award

PRO TIPS:

Please fill out the following form carefully and completely, noting all of the required fields.
All email addresses must be in valid xx@xx.xx format.
16 MB limit on all file uploads.
Your nomination is only submitted once you have reached a screen with a green top bar saying “Thank you for taking this survey”.
Files and supplemental materials may be emailed to awards@aami.org.
Please direct any questions or support needs to awards@aami.org.

Nominee Information:

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* 1. Nominee's Name:

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* 2. Title:

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* 3. Company/Affiliation:

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* 4. Mailing Address:

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* 5. Phone Number:

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* 6. Email Address:

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* 7. Group Nominee Information

If this nomination is for a group or team, please attach the information from the previous entry for each member of the group/team.

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Nominator Information:

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* 8. Nominator's Name:

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* 9. Title:

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* 10. Company/Affiliation:

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* 11. Mailing Address:

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* 12. Phone Number:

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* 13. Email Address:

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* 14. Are you affiliated with the nominee? Note yes or no, and if so, describe your affiliation:

Award Criteria: Nominees must meet all of the following:

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* 15. Nominee has actively participated in meaningful worldwide healthcare technology related projects for at least three years or more. Please describe these projects:

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* 16. Nominee has a leading role in planning or implementing healthcare technology, international outreach or educational programs. Please describe:

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* 17. Nominee displayed volunteerism and altruistic components associated with the projects listed above. Please describe:

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* 18. Nominee possesses outstanding qualities such as being a positive role model, and a passion and dedication whether through work-related humanitarian efforts or through “extra-curricular activities.” Please describe:

Award Criteria: Nominees should meet the following:

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* 19. Nominee has had an impact on quality, accessibility, efficacy, and/or safety of health technology deployment and/or application in international regions. Please describe:

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* 20. Nominee has shared program outcomes through oral and/or printed mediums. Please list:

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* 21. Nominee has worked to establish a sustainable program. Please describe:

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* 22. Nominator Cover Letter:

Upload nominator’s cover letter that provides a rationale statement describing nominee's role in planning or implementing healthcare technology, international outreach or educational programs, the impact on quality, accessibility, efficacy, and/or safety health technology deployment and/or application in international regions due to this nominee's work.

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