Vilcek-Gold Award for Humanism in Healthcare – 2021 nomination form

Thank you for your interest in nominating someone for the 2021 Vilcek-Gold Award for Humanism in Healthcare, a joint program organized by the Gold Foundation and the Vilcek Foundation.

Nominees must be foreign-born, based in the United States, and have made contributions to humanism in healthcare, medicine or public health advocacy in the United States. For more information about nominee criteria, visit our program page.

The nomination period for the 2021 Vilcek-Gold Award is open from November 17, 2020 through January 24, 2021, at 11:59 pm EST.

Please be cautious when working on your submission as any in-progress work will not be saved upon refreshing the page. You will receive a confirmation email upon your successful submission for your records.

For questions regarding your nomination submission, please contact Stacy Morris at smorris@gold-foundation.org. For questions regarding the immigration requirement, please contact Julia Lo at julia.lo@vilcek.org.

 


Fields marked with an * are required

Nominator’s Information:
















Nominee Information:




If your country of birth is not listed, please contact Stacy Morris, at smorris@gold-foundation.org






























We encourage nominators to alert their nominee of their nomination. Has the nominee been notified?




If your nomination is selected as a finalist, they will be required to show proof of their eligible immigration standing by submitting a copy of one of the following documents:

  • Naturalized citizen: U.S. naturalization certificate
  • Permanent resident: U.S. green card
  • H-1B or O-1 visa holder: H-1B or O-1 U.S. visa
  • H-4 visa holder: H-4 U.S. visa and an Employment Authorization Document
  • Deferred Action for Childhood Arrivals recipient: U.S. I-797 notice showing approval of I-821D form
  • Asylee: U.S. I-797 notice showing approval of I-589 form
  • Asylum seeker: U.S. I-797 notice showing receipt of I-589 form and an Employment Authorization Document

Please confirm that the nominee has one of these documents to the best of your knowledge:

 



Tell us about your nominee, your relationship to the nominee, and why you choose to nominate them for this humanism in healthcare award. (1,500 words):

 



Describe the nominee’s work, and its humanistic impact (1,000 words):

 



Please upload nominee’s CV or resume as a PDF:





Please let us know where you learned of this nomination opportunity:





Please help us track the diversity of our nominee pool in our efforts to expand our outreach to historically underrepresented communities.

Please select the below race(s) of your nominee:





Please select the below ethnicity of your nominee: