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2011 Clarence H. Moore Award

The 2011 Clarence H. Moore Award for Excellence for Voluntary Service Nomination Form

Before completing this nomination form, please be sure that you have read and understand the award guidelines. Please ensure you complete all the required fields in your application.

Instructions: Please fill in all the requested information on the nomination form and attach a letter of nomination (two-page limit) signed by the nominator, letter of support (two-page limit), and the annual report. Unfortunately, we are unable to consider unsigned documents.

To be considered, please ensure that you have completed and submitted the online nomination on or before the closing date of the call.

All items marked with an asterisk (*) must be completed.

Note: You must click the “Save” button at the bottom of each page to save your responses.

If you have questions about completing this form, contact
  STEP 2 of 4  
  Roles and Responsibilities of Volunteer Staff *
  Provide information on the roles and responsibilities of the volunteer
staff that help further the organization’s mission (400-word limit)
  Organization Contact Information
  Contact person’s name *
  Title *
  Current position *
  Address *
  City *
  State or province *
  Country *
  Telephone number *
  E-mail address *
  Impact Statement *
  Describe why this organization deserves to win the Clarence H. Moore Award for Excellence for Voluntary Service. Provide a description of specific public
health-related accomplishments using qualitative and quantitative data that
may include information about any of the following: increase of services in the population that is being served, reaching underserved populations, carrying
out activities that are culturally appropriate, short- and long-term impact, intersectoral collaboration highlighting the organization’s contribution and impact in the region of the Americas, with an emphasis on performing work to benefit
the people of Latin America and/or the Caribbean (400-word limit).