Form 1 Nomination form

OMB # 0925-0766

Expiration Date: 04/30/2023

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Rachel Pearline Award Nomination Form

The 9^th Annual Symposium on Global Cancer Research Steering Committee would like to invite nominations for the 6^th Annual Rachel Pearline Award, to be presented at the virtual Symposium on date TBD.

The Rachel Pearline Award honors Rachel Pearline, MD, MPH who received the award named in her memory in 2016 following her death at the age of 38, in November 2015, from gastric cancer. While in medical school, Dr. Pearline completed rotations in South Africa, Haiti, Romania, and rural China where she learned to speak Mandarin fluently. For her work, she received a prestigious Fogarty International Clinical Research Fellowship and Tulane’s award for “Outstanding International Relationships.” Dr. Pearline viewed the practice of medicine as a privilege, always striving to serve her patients better.

As part of the Symposium each year, we recognize one outstanding professional for their excellence in global cancer research and practice. The Steering Committee invites nominations of individuals, at any stage in their career, who have made major contributions to global cancer research and practice. The nominee's work should focus on cancer research and practice in low-and-middle-income countries. The Steering Committee particularly wishes to encourage nominations of individuals currently living and working in a LMIC. The nominee will be recognized at the Annual Symposium on Global Cancer Research where they must give a keynote address that highlights their contributions to global cancer research or practice, and their future perspectives.

The Steering Committee will review nominations based on the following criteria:

1. Demonstrated commitment to and excellence in global cancer research and/or practice.

2. Focus on reducing cancer care inequities through global cancer research and practice.

3. Relevance of the nominee’s work to the 2021 Symposium theme: TBD

4. Nominee’s cancer control activities are either entirely or predominantly in low-and-middle income countries.

5. Nominee’s career stage and potential to contribute to cancer control in LMICs in the future.

The nomination period is: TBD. In order to ensure the selected nominee is able to accept the award and deliver a keynote address, virtually, at the Symposium, please confirm with the individual before nominating them.

Please complete the form below to submit your nomination.

The nominee will be selected and notified in TBD.

Submitter Information

1. Submitter Name:

2. Submitter Institution:

3. Submitter Email:

Nominee Information

1. Nominee Name:

2. Nominee Institution:

3. Nominee Country:

4. Nominee Email:

5. What is your connection to the nominee?

6. □ Confirm (check box) that you have received the nominee’s permission to nominate them for this award.

7. □ Confirm (check box) that the nominee will be able to attend virtually and give a keynote address at the 9^th Annual Global Cancer Research Symposium on TBD.

8. What is the country/region of the nominee’s area of focus?

9. What is the nominee’s scientific area of focus within global cancer research and practice?

10. In 300 words or less, please describe why you are nominating this individual for the 2021 Rachel Pearline Award. Why do you believe the nominee has achieved excellence in global oncology and would provide a compelling keynote address for the 9^th Annual Global Cancer Research Symposium?

Statement of attestation:

I attest that the information I have provided in this form is correct and I have received explicit permission from _____ for nomination for this Award.