Ethiopia – PEPFAR HEROES – NOMINATION FORM

PEPFAR HEROES – NOMINATION FORM

Nominations are now being accepted for the United States Mission in Ethiopia’s “PEPFAR Heroes” Award. PEPFAR is the U.S. President’s Emergency Plan for AIDS Relief. Nominations must be submitted on this form to PEPFARHeroes@State.Gov or in hard copy delivered to the U.S. Embassy in Addis Ababa, Ethiopia by midnight, November 15, 2009. Anyone can nominate a “PEPFAR Hero.” Eligible “Hero” nominees may be contributing to the fight against HIV-AIDS in Ethiopia in a wide-range of ways, including as community organizers, doctors, nurses, health extension and social workers, journalists, researchers, artists, publicists, or religious leaders. Nominees must be Ethiopian citizens. A committee composed of representatives from the U.S. Mission, PEPFAR partner organizations, and the Ethiopian Government will select five “PEPFAR Heroes” who will be invited to a ceremony in celebration of World AIDS Day at the U.S. Embassy. The U.S. Mission will make a contribution to an HIV-AIDS charitable organization of the Hero’s choice, in the name of the selected Hero.

Please provide the following information about the nominee:

Name:____________________________________________________________
Organization:_______________________________________________________
Focus Town/Region:__________________________________________________
(Please list the town or region where the nominee focuses his/her work or write “countrywide”)
Focus Community:___________________________________________________
(Please note if the nominee works with a particular community, i.e. HIV-positive people, orphans and vulnerable children, etc.)
Sex: Male:__________ Female:__________
Is the nominee an Ethiopian citizen?: Yes:_____ No:_____
(Only Ethiopian citizens are eligible)

Is the nominee working in a PEPFAR-funded activity? If so, which:____________________________________________________________
(Note: Work in a PEPFAR-funded activity is not required for this award.)

Justification: Please attach an explanation of the contribution that the nominee has made to address the HIV-AIDS crisis in Ethiopia. In your justification, please provide specific examples of the impact that the nominee’s work has on combating the disease and the inspiration and hope that the nominee has given to Ethiopians living with HIV-AIDS or affected by it. In submitting your nomination, some of the factors you may consider are: 1) how has the person made a difference within their community; 2) how has the nominee increased awareness and public knowledge of HIV-AIDS; 3) how has the nominee improved the lives of Ethiopians living with HIV-AIDS, and members of their families. Please limit your narrative to 500 words.