2020 Dr. William K. Rashbaum Abortion Provider Award
  • Nomination Form

    Physicians for Reproductive Health is dedicated to equity and justice. We aim to recognize physicians of color, those practicing in areas most affected by anti-abortion policies, and who represent diversity in experience.


    How to submit a nomination: Enter your contact information below (the nominator), followed by the contact information for the doctor you are nominating (the nominee). For the nominee statement, answer the question prompts in detail. Please limit your response to 750 words. 

     

    After this form is submitted, please send the nominee's CV to dkapsalakis@prh.org. Physicians staff will then contact the nominee to confirm their acceptance of the nomination. The deadline for all materials is Monday, November 25, 2019. 

    Thank you in advance for your participation.

  • The Nominator: 

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      First Name
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      Last Name
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      City
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      State
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      Phone
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      Email
  • *Briefly describe your relationship to the nominee:
  • The Nominee: 

    • *
      First Name
    • *
      Last Name
    • *
      City
    • *
      State
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      Phone
    • *
      Email
  • Nominee's current professional title (if applicable):
  • *Nominee's medical specialty:
  • Nominee Narrative: 

  • Based on the following questions, please provide a detailed narrative statement with examples. This narrative is absolutely essential in helping the Nominations Committee familiarize themselves with the nominee. Please limit your response to 750 words maximum.


    • In what capacity do you know the person you are nominating?
    • How long and where has the nominee provided abortion care? Is the nominee currently providing abortion care?
    • Describe how the nominee is a mentor/educator to others in the field.
    • Has the nominee demonstrated extraordinary compassion towards patients? 
    • How has the nominee demonstrated being an advocate for reproductive health and rights? 

  • *Narrative statement:
  • Additional information (e.g. links to published articles written by or about the nominee, op-eds, press mentions):

That's all, folks!

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