HANDS Honors Nomination Form

Any ASGE member in good standing may submit a nomination. Non-member community partners may also submit nominations if an ASGE member is listed as the nominee or primary contact and all requirements are met. Self-nominations are permitted.

Required Materials

Completed Nomination Form
Beneficiary Verification Form completed by an eligible verifier using an organizational email address when available

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

Nominee Information

Note: Select the Nominee Type first, as it determines which required fields appear in the form.

Nominee's Full Name

Nominee's Credentials (For Individuals)

Primary Institution/Organization

Nominee's Email

Nominee's Phone

Nominee's ASGE Member ID

Training and Eligibility

Formal Training Completed (Institution and Year)

Transplant Hepatology Fellowship Completed (If Applicable; Institution and Year)

Board Certification(s) (Optional)

Attestation

I confirm the individual nominee or members of the group (where applicable) have received formal training related to GI/hepatology (or international equivalent).

Charitable Activity Overview (300-500 words)

Brief Description of the Charitable Service Initiative

Location(s) Served (City/State/Country)

Beneficiary Population(s) Served

Setting

Safety-Net Clinic

Community Program

Hospital-Based Charity Care

Mission-Based Care

Other...

Type of Work

Endoscopy

GI Consultative Care

Hepatology

Screening/Linkage-To-Care

Training/Capacity Building

QI/Protocol Development

Other...

Service Period and Effort (select at least one metric)

Award Year Service Dates

Estimated Volunteer Hours or Days

Estimated Number of Patients Served and/or Procedures Performed (Aggregate Estimates Are Acceptable)

Frequency

One-Time

Quarterly

Monthly

Weekly

Ongoing Program

Role and Collaboration

Role of Nominee

Founder/Leader

Medical Director

Core Recurring Volunteer

Episodic Volunteer

Consultant/Advisor

Other...

Key Collaborators/Partners (Organizations and Roles)

For Groups: List Key Contributors and Indicate Which Are ASGE Members

Impact (5 bullets maximum)

What Changed for the Community Because of This Work? (Outputs and Outcomes When Known)

Sustainability/Continuity Plan (Especially for International Efforts)

Compensation and Funding Disclosure

Were Any Services Compensated Beyond Expense Reimbursement?

Yes

If Yes, Explain

Were Expenses Reimbursed (Travel, Lodging, Supplies)?

Yes

If Yes, Explain

Any Relevant Financial Relationships or Conflicts to Disclose?

Yes

If Yes, Explain

Optional Materials

Photos (No Patient Identifiers)

Add another

Program Flyers or Impact Reports

Add another

Links To Media Coverage

Testimonials

Required Attestations

Attestation One

The charitable activities were voluntary and not required by Certificate of Need, employer contract, privileging requirement, or similar obligation.

Attestation Two

No patient-identifiable information is included in this submission or attachments.

Attestation Three

I understand ASGE may contact the beneficiary organization to verify the submission and may audit a subset of submissions.

Attestation Four

I grant ASGE permission to list my name/group name as an Honoree if approved (publication is optional and may require additional consent).

Submitter Information (if different from nominee)

Submitter Name

Submitter Email

Submitter Phone

Relationship To Nominee

Note: 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.