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Community Service Award
Online Form

Deadline for Nominations: Friday, March 16, 2012 New Extended Deadline is Friday, March 30, 2012

Please complete the entire nomination form. You will be able to preview your nomination before submitting. If you have any questions, please contact the office (or 617-432-3020) before submitting.

  • Please complete the entire nomination form.
  • Please DO NOT insert hard returns (i.e. paragraph breaks) and DO NOT use quotes or speech marks within your narrative.
  • You will be able to preview your nomination before submitting. Please review it carefully to make sure that your nomination has been submitted in its entirety.
  • We strongly recommend that you save any narrative you write as a Word document in the event of technical difficulty.
If you experience difficulty submitting your nomination on-line, please contact Nancy Kaufman at 617-432-1037 or dcp_csaward@hms.harvard.edu

 
I. NOMINEE INFORMATION

Nominee is:

First Name:

Last Name:

Institutional Affiliation:
Department/Program:

Title (Academic or Administrative) or
Year (Student or Trainee):

Street Address:
City:
State:
Zip:
Telephone:
Fax:
E-mail:
II. NOMINEE ACTIVITIES
A. Purpose of organization/activity for which the nominee serves (including whom it serves):
Please DO NOT insert hard returns (i.e. paragraph breaks).
B. Length of service with organization/activity:
C. How frequently does the nominee volunteer at the organization/activity?

Other:

 
D. Impact of the nominee's work on the organization/activity and those it serves:
Please DO NOT insert hard returns (i.e. paragraph breaks).
E. Has the nominee's work with the organization/activity been: (Although this information is not required, if you have knowledge of the following items in questions 1, 2, and 3, please respond.)
1. Externally Funded?
If so, by whom?
2. Replicated?
If so, by whom?
3. Disseminated?
a. If yes, presented?
If so, by whom?
b. If yes, published?
If so, by whom?
F. Recognition nominee has received for this & other community service work:
Please DO NOT insert hard returns (i.e. paragraph breaks).
III. ORGANIZATION(S) / PROGRAM(S) FOR WHICH THE NOMINEE SERVES

Organization Name:

Organization Address:

Organization Telephone:

Organization Email:

Organization Website:

If nominee serves at several organizations, please list them separately in the field below:
Please DO NOT insert hard returns (i.e. paragraph breaks).

If your nominee becomes a finalist, we may need additional information. Please provide the information for a contact at the organization/program if you are aware of one.
Contact Name
Contact Title
Contact Phone
Contact Fax
Contact Email
IV. NOMINATOR INFORMATION

First Name:

Last Name:
Institutional Affiliation:
Department/Program:
Title or Year:
Street Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
Note: If your nominee is a finalist, we may contact you or the nominee for a copy of his/her CV or resume.