1. Patient Support Group (PSG) Name : ____________________ ( if applicable) Category : _____________________________
Date of Incorporation/Registration ( if applicable)
Registration Number
Date :
____________________
Name of contact person who heads the PSG
(PSG) Address
Is the PSG affiliated with a medical doctor, hospital or institute
Address
Yes No
If yes: Name ( hosp/ doctor/ institute) : ______________________
Referees Details ( 2)
Name 1 :
Organization:
Relation to the Nominee:
Name 2:

2. Various services provided by the PSG
Why did you choose this activity and area of intervention

3. How many years has the Patient support been operational
What are the key activities performed within the group
Individuals helped in the past 2 yrs ( min) to 5 yrs (max)

4. Annual Budget
Number of Staff
Full time
Part time
Volunteers
Main source of funding

5. Impact of the activity ( 3 patient stories)

6. Impact of the activity ( 3 patient stories)

7. Collaboration with other organizations / Individuals
Recognition/ Achievement
Name of Office bearers and their details

8. Any other information you would like to share
A brief (500 words max) describing how the prize (fund) will be used to achieve the objective of the PSG
Any other information you would like to share