Digital Health Champion Nomination Form

NOMINEE INFORMATION

Name of Company / Organisation / Person *

Primary area of digital health *

Website (if applicable)

Contact Person / Representative (if known)

NOMINATOR INFORMATION

Name *

Email *

Telephone *

Organisation *

Date Submitted *

ELIGIBILITY CONFIRMATION

Please select *

The nominee has undertaken a digital health initiative, innovation, programme, service or contribution with demonstrable healthcare value. The information provided is accurate to the best of my knowledge.

NOMINATION SUMMARY

Contribution / Initiative

Briefly describe the nominee’s digital health initiative or contribution. What healthcare need or challenge does it address? [Suggested maximum: 120 words]

Impact & Outcomes

What measurable or observable difference has it made? Include key results such as improved access, quality, efficiency, patient experience, clinical outcomes, reach or adoption.[Suggested maximum: 150 words]

Innovation & Significance

What makes this contribution innovative, distinctive or significant within digital health? [Suggested maximum: 100 words]

Sustainability / Scalability

Briefly explain whether the initiative can be sustained, expanded or replicated, and its potential for continued impact.[Suggested maximum: 80 words]

Supporting Evidence / References

List up to three relevant links, publications, awards, reports, testimonials or other evidence supporting the nomination.