sunil k. rao, md memorial retina fellowship award - FAAO

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresPurposeThe purpose of the Sunil K. Rao, MD Memorial Retina Fellowship Award is to acknowledge andprovide educational support for ophthalmologists demonstrating outstanding achievement inretinal disease. The award provides financial support that enables up to two retina fellows toattend the 2013 Annual Meeting in New Orleans.In 2012, Dr. Sunil K. Rao, an ophthalmologist specializing in retinal disease, passed awaysuddenly at age 34. Dr. Rao completed his residency training in 2008 at Brown University andcompleted his medical and surgical vitreoretinal fellowship in 2010 at The New York Eye and EarInfirmary. Throughout his life and career Dr. Rao had a boundless enthusiasm for learning andteaching medicine and ophthalmology. He was extremely generous to his patients, family andfriends, and will truly be missed by all those who were fortunate enough to have known him.As a tribute to his memory and passion for ophthalmology, his colleagues, family and friendshave established a memorial fund through the Academy Foundation. In 2013, the AcademyFoundation will grant the Sunil K. Rao, MD Memorial Retina Fellowship Award to twodistinguished ophthalmologists. The award will consist of:• Complimentary Academy Plus course pass at the 2013 Annual Meeting• Complimentary registration for the 2013 Retina Subspecialty Day meeting and oneBreakfast With the Experts roundtable• Complimentary retina Skills Transfer course at the 2013 Annual Meeting• $2,500 stipend for travel related to the 2013 Annual Meeting (airfare, hotel, meals andground transportation)• $1,250 voucher for educational products from the Academy Store• An award certificate recognizing the Retina Fellow’s achievementQualifications and Criteria for Nomination1. The nominee must currently be a Retina Fellow and in good standing with the AmericanAcademy of Ophthalmology.2. Nominations may be made by program directors, department chairs, societies orindividuals. Applicants may also choose to nominate themselves.3. The nominee must be a legal resident of the United States.4. Successful nominees should have a professional resume that demonstrates particulardedication and/or achievement in the areas of scholarship, biomedical ethics, teachingand/or professionalism. Particular attention should be paid to involvement in Academyactivities in these areas.5. If awarded, the recipient will be required to submit a W-2 in accordance with IRSregulations.

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresSunil K. Rao, MD Memorial Retina Fellowship Award Nomination Procedures1. All forms must be typed. Hand-written nomination forms will not be accepted. You mayalso visit www.faao.org to complete a nomination form online. For questions, please contactthe Academy Foundation’s Development Office by phone at (415) 447-0361, fax (415) 561-8567or e-mail faao@aao.org.2. At least two letters of recommendation must be included with the nomination form.3. The deadline to receive nomination forms is July 15, 2013. The review committee will selectthe winners. Recipients will be notified by August 31, 2013.Selection of RecipientsThe review committee will consider only those nominations that meet the qualification criteriadescribed above. In reviewing each nomination, the committee will verify references providedby the nominee, and if necessary, gather additional information in making their decision.Selection of recipients will be determined on the basis of factors including, but not limited to:type of clinical or educational contribution; its quality and impact in the field of retinal disease;the demonstration of passion for the field; the nominee’s academic achievements; and therecommendations of the nominating body and/or individuals identified on the nominationform, or others whom the review committee may consult.A maximum of two recipients will be selected in 2013; therefore, not all nominees will receivethe Sunil K. Rao, MD Memorial Retina Fellowship Award.

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresInstructionsThe Sunil K. Rao, MD Memorial Retina Fellowship Award nomination form should becompleted by a program director, department chair, society or the applicant.Please do not write “SEE ATTACHED C.V.” This nomination form must be completed in itsentirety.The review committee will evaluate this nomination. You must type the information requested– hand-written applications will not be accepted. Use an additional page if necessary tosupplement your answers.Nominee ProfileName of Nominee:Address:City: State: Zip Code: ______________Telephone:Fax:E-mail:Nominated by:(Name or Nominating Body)

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresClinical Activities and Achievements (Limit each answer to a maximum of 150 words)1. Please describe particular activities and/or scholarly achievements in the field ofophthalmology.2. Please describe other activities and/or achievements as they relate to professionalism inthe field of ophthalmology.

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination Procedures3. Please note your participation in any programs or projects sponsored by the AmericanAcademy of Ophthalmology.4. Please provide a brief personal statement describing your career goals.

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresName:Title:5. Please list the name and contact information for the individual or nominating bodysubmitting this form.Nominating Body:Address:City: State: Zip Code: ______________Telephone:Fax:E-mail:

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination Procedures6. Please list up to three individuals that the review committee may contact to verifyinformation concerning the nominee’s clinical or educational contribution.I. Name: Title:Organization:Address:City: State: Zip Code: ______________E-mail:II. Name:Title:Organization:Address:City: State: Zip Code: ______________E-mail:III. Name:Title:Organization:Address:City: State: Zip Code: ______________E-mail:

SUNIL K. RAO, MD MEMORIAL RETINA FELLOWSHIP AWARDInformation and Nomination ProceduresPlease include any supplementary materials you would like the review committee to considerconcerning this nomination.Return the completed form (e-mail or mail) by July 15, 2013 to:1. E-mail:faao@aao.org2. Mail:Award Review Committeec/o Development OfficeThe Foundation of the American Academy of Ophthalmology655 Beach St.San Francisco, CA 94109-1336Additional Contact Information:Phone: (415) 447-0361Fax: (415) 561-8567E-mail: faao@aao.org