António Champalimaud Vision Award

António Champalimaud Vision Award Nomination Form – page 1/6

António Champalimaud Vision Award Nomination Form

Nomination forms must be fully completed and signed by the nominator on page 6. In addition please include in your entry a bibliography pertaining to the candidate’s work with the five most relevant articles clearly marked (please include up to five publications since 2010) as well as up to three supporting letters by people not affiliated with the organizations with which the candidate is involved.

Please submit by mail all material typed in English, both on paper and disk/digital form (Microsoft word or adobe.pdf format), to:

Vision Award Administration Champalimaud Foundation Av. Brasília 1400-038 Lisbon, Portugal

Completed Entries must be received in full by the Foundation not later than December 31st, 2015.

For more information please contact: T (+1) 617 959 5277 or (+351) 210 480 200 F (+351) 213 568 169 [email protected] António Champalimaud Vision Award Nomination form – page 2/6

Candidate Information*

Candidate

Primary Institutional Affiliation(s)

Address(es)

Postcode(s)

Country (s)

Telephone / Fax

* Please indicate address and email to which correspondence should be addressed.

1 Suggested Citation of the Candidate’s Contributions Please provide a suggested citation which succinctly presents the important aspects of the contribution(s) which you propose to be recognized by the award. (75 words or less)

António Champalimaud Vision Award Nomination form – page 3/6

2 Description of the Candidate’s Work What has been the major scientific problem addressed by the candidate? Why is it important? What are the scientific approaches implemented? Please include background references to the problems addressed, the nature of the scientific activities executed, the contemporary relevance of these, as well as a description of the methods/procedures used and approaches taken. (400 words or less)

3 Candidate’s Achievements to Date What are the candidate’s key original research contributions that have provided exceptional advances in the field? What makes the candidate’s work exceptional and why? Please describe in-depth the research accomplishments that are being recognized. How have these discoveries accelerated the progress of the field? Please reference in the attached bibliography the publications that support these claims. (300 words or less)

4 Impact of the Candidate’s Activities A. What has been the measurable and/or tangible impact of the candidate’s discoveries? This relates to the overall impact of the scientific contributions for which the candidate is being nominated. What have been the implications of the candidate’s findings for subsequent basic, translational, clinical research and/or clinical practice? How have the candidate’s discoveries affected scientific thinking and subsequent basic, translational or clinical research, clinical practice or public health programs? (200 words or less).

B. What are the implications of the candidate’s present research efforts? (75 words or less)

Other Major Contributor Groups Should the award be shared with other investigators or groups of investigators? Provide evidence that the candidate uniquely deserves recognition for the body of work being recognized; if others have made equally important contributions please describe what these were, who made the contributions, and the status of their present work. (Up to 10 references may be provided - 75 words or less).

Nominator Information

Primary Institutional Affiliation

Address / Postcode

Country

Telephone / Fax

Relationship to Nominee(s)

Signature of Nominator