Award Nomination Form 1Nomination screening2Nomination information3 Does this rescue involve a human victim who would have otherwise lost their life?* Yes No I don't know Did the rescuer risk their life or serious physical injury?* Yes No I don't know Did this rescue act occur in the United States, Canada, or the waters thereof?* Yes No I don't know Did the rescue occur in the last two years?* Yes No I don't know Unfortunately this nomination does not meet the minimum requirements of the Carnegie Medal. Return to home page Please complete this form with as much information as known in the fields below. If any information is unknown, please leave blank. When finished, please click the “submit” button.Relationship to the RescueAre you an eyewitness to this rescue?YesNoIf not, how did you hear about the rescue? Rescue DetailsDate of Act MM slash DD slash YYYY For an act to be considered by the Hero Fund, it must have occurred within the last two years.Time of Act : Hours Minutes AM PM AM/PM RescuerRescuer Full NameRescuer AgeRescuer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Rescuer Email Rescuer OccupationRescuer Telephone Rescued VictimVictim Full NameVictim AgeVictim Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Victim Email Victim OccupationVictim Telephone Scene of AccidentLocation of where rescue occurredFor an act to be considered by the Hero Fund, it must have occurred in the U.S., Canada, or waters thereof.Please provide a brief description of scene.Describe the victim's life threatening situation. RescueHow did the rescuer learn of the accident/situation?Was the rescuer obligated to aid the victim?YesNoIf so, what was the nature of the obligation?Please describe what the rescuer did to save the victim.Was the rescuer assisted by anyone?YesNoIf so, by whom?What injuries, if any, did the rescuer sustain?What injuries, if any, did the victim sustain?Do you think the rescuer risked his/her life performing this act?NoYesIf so, why?Please list names, present addresses, and approximate ages of eyewitnessess, if any. Your informationYour NameYour AgeYour Telephone NumberYour Email Your Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How did you hear about us?Contacted by the CommissionFacebookTwitterNews ArticleWord of MouthOtherCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
