ISVIR - INTERNATIONAL GOLD MEDAL AWARD

Basic Detail *

ISVIR Membership No. (Format: ISVIR-LM-XXXX) *

Salutation *

Gender *

First Name *

Middle Name

Last Name *

Date of Birth *

Email *

Phone Number *

City *

State *

Country *

Zip Code *

Address *

Designation *

Hospital / Institute Address *

Nomination Form *

Accepted: PDF, DOC, DOCX, JPG, JPEG, PNG. Maximum 10 MB.

CV (maximum eight pages), highlighting contributions to India *

Proof of country of practice *

Narrative statements *

Conflict-of-interest and industry disclosures *

Proposer (ISVIR Membership No.) *

Seconder (ISVIR Membership No.) *

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Scoring Details *

Please download the file to view the marks allocated to each item.

Enter the marks you are claiming and upload one supporting document per domain. The proof upload spans all items in that domain.

Domain / item	Basis	Max	Marks claimed	Supporting document for domain
Domain 1 — Service to ISVIR (domain maximum: 85)
Years of membership	A1	25		Upload proof for Domain 1 — Service to ISVIR One combined PDF or supporting file for this domain. Optional if no claim.
National office-bearer and EC posts	A1	25
Committees, subcommittees, ISVIR guidelines	A1	10
Junior Wing posts	A1	10
Organisation of ISVIR national conferences and meetings	A1	15
State Chapter posts and events	A2	10
Domain 2 — Scientific contribution (domain maximum: 120)
Journal articles (JCIR premium applies)	A3	50		Upload proof for Domain 2 — Scientific contribution One combined PDF or supporting file for this domain. Optional if no claim.
Textbooks, atlases and chapters	A3	25
Patents and documented innovations	A3	15
Clinical trials and competitive grants	A3	15
National guideline bodies	A3	15
Domain 3 — Orations and distinctions (domain maximum: 35)
Orations and named lectures	A6	15		Upload proof for Domain 3 — Orations and distinctions One combined PDF or supporting file for this domain. Optional if no claim.
Awards, fellowships and board certification	A6	20
Domain 4 — Teaching (domain maximum: 60)
Faculty years and thesis guidance in Recognised IR Training Programmes	A5	30		Upload proof for Domain 4 — Teaching One combined PDF or supporting file for this domain. Optional if no claim.
Invited lectures, workshops, chairing, course direction	A5	30
Domain 5 — Editorial roles (domain maximum: 30)
JCIR and other journals	A7	30		Upload proof for Domain 5 — Editorial roles One combined PDF or supporting file for this domain. Optional if no claim.
Domain 6 — International service, training leadership and outreach (domain maximum: 40)
International society posts	A8	15		Upload proof for Domain 6 — International service, training leadership and outreach One combined PDF or supporting file for this domain. Optional if no claim.
Established an ISVIR-recognised or university IR training programme (10 per programme)	Award item	10
Director or Head of a structured IR fellowship programme (5 per programme)	Award item	5
Public service and outreach	A9	10
Total marks claimed			0	Printed maximum: 370

Domain totals cannot exceed the maximum shown for each domain. The supplied sheet lists a total maximum of 370.

I confirm that the information and supporting documents provided are true and complete. *