Award Nomination Form – Carnegie Hero Fund Commission

Please complete this form with as much information as known in the fields below. When finished, please click the “submit” button.
Relationship to the Rescue
Are you an eyewitness to this rescue?
If not, how did you hear about the rescue?
Rescue Details
Date of Act
Date Format: 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

: HH

MM
Rescuer
Rescuer Full Name
Rescuer Age
Rescuer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Rescuer Email
Rescuer Occupation
Rescuer Telephone
Rescued Victim
Victim Full Name
Victim Age
Victim Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Victim Email
Victim Occupation
Victim Telephone
Scene of Accident
Location of where rescue occurred
For 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.
Rescue
How did the rescuer learn of the accident/situation?
Was the rescuer obligated to aid the victim?
If so, what was the nature of the obligation?
Please describe what the rescuer did to save the victim.
Was the rescuer assisted by anyone?
If 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?
If so, why?
Please list names, present addresses, and approximate ages of eyewitnessess, if any.
Your information
Your Name
Your Age
Your Telephone Number
Your Email
Your Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How did you hear about us?
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Phone
This field is for validation purposes and should be left unchanged.

Relationship to the Rescue

Rescue Details

Rescuer

Rescued Victim

Scene of Accident

Rescue

Your information