Aesculapius Award for Excellence in Health Communication
Application to judge World Wide Web sites and/or television or radio PSAs

Please complete and fax this form to 301-320-0978 (or email to hii@hii.org)
Submit resume or brief biographical sketch highlighting relevant qualification & experience.

The Aesculapius Award, named for the ancient Greek God of healing, recognizes outstanding organizations that have provided health information to the public through the use of World Wide Web (WWW) sites or television or radio public service announcements (PSAs). The award is intended to encourage excellence in health communication and promotion. The Health Improvement Institute invites participation on volunteer panels to judge WWW sites or television and radio PSAs. Each judge reviews about 8 -10 WWW sites or 5-6 PSAs at their own convenience. The deadline for entries is the first Friday after Labor Day. Judges are asked to complete their evaluations by the end of October.

Name: __________________________________________________
Organization:
 __________________________________________________
Position/Title:
 __________________________________________________
Address:
__________________________________________________
__________________________________________________
Telephone:
________________ Fax:__________________________
Email:
__________________________________________________

I would like to judge the following category(ies):
[ ]  World Wide Web sites   [ ]  Television PSAs   [ ]  Radio PSAs
Please check all of the types of organizations for which you work or which you represent:

[ ] Awards/Ratings organization [ ] Law firm
[ ] Computer hardware manufacturer/distributor [ ] Managed care organization (e.g., HMO, PPO)
[ ] Consulting company [ ] Media (e.g., TV, radio, newspaper)
[ ] Consumer organization [ ] Non-health industry association
[ ] Federal government official [ ] Non-health professional association
[ ] Health care provider (e.g., hospital) [ ] Pharmaceutical/device manufacturer/distributor
[ ] Health insurer [ ] Print or electronic publisher
[ ] Health trade association (e.g., AHA, JCAHO) [ ] Software manufacturer/distributor
[ ] Health professional association (e.g., AMA) [ ] State/local government official
[ ] Independent consultant/Individual [ ] Telecommunications/cable company
[ ] International organization (e.g., UN, WHO) [ ] Voluntary health association (e.g., Red Cross)
[ ] Internet provider [ ] Other, please specify:

Adverse professional events - In the last 5 years, have you been, or are you currently, involved with any event that could call into question your suitability to be a judge (e.g., adverse action regarding quality of care, professional conduct, research integrity, etc)? [ ] Yes, please explain [ ] No

Comments - including any other relevant qualifications or experience, explanations of adverse professional events, etc.

Signed:_________________________________________ Date:_______________________________

Version 3.2; revised September 11, 2008