ISVIR 2027 - PUBLIC SERVICE EXCELLENCE AWARD

Step 1 — Applicant Details *

ISVIR Membership No. (Format: ISVIR-XXXX, C-XX or S-XX) *

Salutation *

Gender *

First Name *

Middle Name

Last Name *

Date of Birth *

Email *

Phone Number *

City *

State / Province *

Country *

Residential / Correspondence Address *

Postal / ZIP Code *

Designation *

Hospital / Institute Address *

Upload CV *

PDF, DOC or DOCX; maximum 10 MB.

Nomination Form (confirmed online by both Nominators) *

(a) Nominator 1 *

Medical Superintendent, Dean, Director or Head of the Nominee's institution.

PDF, DOC or DOCX; maximum 10 MB.

(b) Nominator 2 *

A Member with personal knowledge of the Nominee's work.

PDF, DOC or DOCX; maximum 10 MB.

Institutional verification on letterhead with seal *

Proof of employment and service period *

Procedure and patient-volume data for the preceding three years from institutional records *

Upload at least one document supporting public service, service record or institutional impact. Multiple files allowed; maximum 10 MB each.

Cancel

Scoring *

Sustained commitment is scored by fixed bands from the service record. Score each other criterion against the descriptors below. Record a one-line reason for each criterion score.

Scoring descriptors: Exceptional (90–100% of criterion maximum); Strong (70–89%); Adequate (50–69%); Limited (below 50%).

Criterion	Evidence	Max	Score	One-line reason	Supporting file (optional)
Access and clinical impact: patients served, IR services introduced, patients who would otherwise have travelled or gone untreated	Institutional data	30			Optional, max 10 MB
Sustained commitment: years of service in the qualifying setting	Service record	20			Optional, max 10 MB
Context and constraints of practice	Form, verification	15			Optional, max 10 MB
Adaptability and innovation within constraints	Form, Nominators	15			Optional, max 10 MB
Training of local staff and strengthening of the local health system	Form, Nominators	10			Optional, max 10 MB
Patient safety and quality: audit, complication records, outcome follow-up	Institutional records	10			Optional, max 10 MB
Total score			0 / 100	Maximum score: 100

Scores must not exceed the maximum for each criterion. The sustained commitment score is restricted to the fixed service-record bands shown above.

I confirm that the applicant details, service record, scores and supporting documents submitted are accurate and complete. *