HANDS Honors Beneficiary Verification

One completed verification form is required for all nominations. The verifier must be affiliated with the beneficiary organization and able to confirm the dates, nature of service, and that the service was charitable or voluntary. ASGE may contact the verifier for confirmation and may conduct random audits.

Required Materials

Optional Materials

  • Photos (no patient identifiers) and/or brief testimonials suitable for publication
  • Supporting materials such as program flyers, de-identified aggregate impact reports, or media coverage

Beneficiary Organization

Verifier Information

Service Confirmation

Type of Service Provided (Check All That Apply):

Was the Service Provided as Charitable/Voluntary Work (No Substantial Compensation)?

Was the Service Required by a Contract, Employer Obligation, Certificate of Need, or Privileging Requirement to Your Knowledge?

In 1-2 sentences, describe the value of the nominee’s contribution to your community/organization:

Verification Attestation

If you are having trouble submitting the form, please scroll up and review all required fields to ensure they have been completed.

Contact Ellissa Langston at elangston@asge.org with questions about ASGE's HANDS Honors Program.