CSA2007

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The University of Virginia Health System would like to reward extraordinary dedication and excellence for volunteerism on community service and outreach.

Nominating Procedure: Anyone may make nominations (faculty, staff, or community member). The major elements to be considered for the award are:

Gives freely and unselfishly of their time to community activities
Inspires others and acts as a role model
Has a positive impact on the direction and success of community projects, programs, and individuals
Improves the lives of others

Please provide brief responses to the following questions regarding the nominee's community service.

Nominee's Name:

Nominee's Dept/Phone:

Nominated by (Name):

Nominated by (Dept/Phone):

Volunteer community service performed/hours donated:

Brief description of work done by nominee:

Brief description of levels of effort and initiative displayed:

How did nominee exceed the expectations of their position by providing this community service:

How did the nominee's service help to foster collaboration in the community:

What makes the nominee unique:

Please include contact information for two individuals (references) who are knowledgeable of the nominee's achievements and character and who are from the community group served.

Reference 1 Name

Reference 1 Organization

Reference 1 Phone Number

Reference 1 E-mail

Reference 1 Address (street)

Reference 1 Address (City, State, Zip)

Reference 2 Name

Reference 2 Organization

Reference 2 Phone Number

Reference 2 E-mail

Reference 2 Address (Street)

Reference 2 Address (City, State, Zip)

In addition to this form, please send a resume or curriculum vitae (if available but not required), a detailed description of the individual's service achievements, and any other appropriate supplementary materials by August 8, 2007 to:

Office of Community Relations, Outreach, and Service
P.O. Box 800224
Charlottesville, VA 22908