EmailMe Form - 2012 NCHN Awards: Nomination Form

NOMINEE INFORMATION

Enter information as it should appear on all printed materials and award

Name of Nominee *

First Last

Organization *

Number of Years Active *

For nominations of Individuals: enter the number of years as network leader
For nominations of organizations: enter the number of years the organization has been in existence

Area(s)/State(s) affected by the Nominee's work *

Nomination Category *

The Outstanding Network Leader of the Year

The Outstanding Network of the Year

The Outstanding New & Emerging Network Leader

Friend of NCHN

Nominator Information

If your nominee is chosen, you will be asked to contact the honoree upon winning and be the central communications for the honoree.

Name of Nominator *

First Last

Organization

Nominator's Email *

NARRATIVE & DOCUMENTATION

Please note that each nomination must include a written narrative, no more than 600 words, about why the person or organization being nominated should be considered for the selected award. This narrative is the primary instrument on which the nomination will be judge and should be based on the criteria listed within each award category, which is described in the Awards Program Guidelines.

Please include the significance of the nominee’s work within their network, community, state, and NCHN and explain how health networks have benefited. If your nominee is chosen, your written description will be used at the awards banquet. The description should include those attributes that set this nominee’s work apart from others in their field. For example: demonstrable lasting change in health status, innovation or creativity, impact as demonstrated by replication or community acceptance, or ongoing influence in health network improvement.

A resume or CV may also be included for the nominations of individuals and does not count toward the 600 word limit.

NOTE: Your nominee is competing against others. The only information that the committee will use in making its decision is what you provide in your written description. Please be very specific about why your nominee should be chosen.

Narrative *

This is required. If you are uploading your narrative as a document, enter "See attachment" and attach your document below.

Optional: Add your Narrative as an attachment

You may attach your narrative if you have saved it as a Word document or pdf

SUPPORTING DOCUMENTATION

Attachments which enhance and support the award entry may be included. Supporting letters are encouraged and are limited to two (2). Letters should address the factors to be considered as outlined in the Awards Program Guidelines. Please note that it is not necessary to include documentation to be considered for the award.

Supporting Documentation 1:

Supporting Documentation 2:

Photo of the Nominee (optional):

Signature

After entering your signature below and submitting the form, you will be redirected to the 2012 Awards page and will receive a confirmation email which includes your entry.

Thank you for your assistance in recognizing excellence in health networks!

Questions should be sent to rdavis@nchn.org

Signature *

Enter your name to electronically sign the nomination

Date Time *

MM / DD / YYYY