WEST VIRGINIA PUBLIC HEALTH ASSOCIATION

HALL OF FAME
NOMINATION FORM

    1.  I wish to nominate the following person to the West Virginia Public Health Hall of Fame.

Name:__________________________________________________________

Address (if living):_________________________________________________

_______________________________________________________________

Phone:__________________________________________________________

                    Birth date: __________________Birthplace:____________________________

         Contact person if deceased - 9 Spouse, 9 Son, 9 Daughter, 9 Other: ____________
                                                    (Please mark one box)

                   Name:__________________________________________________________

                   Address:________________________________________________________

                   Date Nominee Deceased:___________________________________________

   2.   Approximate years of active public health service:___________________

   3.   Explain briefly the contributions the nominee has made in service to the field of Public Health. Indicate
         with an asterisk (*) which contributions are considered of major importance and why you think so.
         Elaborate on separate sheets if necessary.

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   4.    List organizations related to Public Health of which nominee was a member over the period of active
          service, and any offices held. Give dates and span of time. Include boards, commissions and major
          committees related to Public Health.

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  5.    Awards: List West Virginia awards, honors or citations; national awards, honors or citations; and
         industry awards, honors or citations.

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                    _______________________________________________________________

                    _______________________________________________________________

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   6.    Background (education, family, previous occupation, etc.)

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   7.    Explain the nature of outstanding non-Public Health service the nominee has contributed within
          the state. List boards, commissions and major committees.

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                    _______________________________________________________________

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   8.    Indicate the personal traits which distinguish this person as outstanding among their peers.

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   9.   If your nominee is not chosen for the Hall of Fame Award, would you like them to be considered
         for a Public Health Award? 9 Yes 9 No (please mark one box)

         I certify the above statements are true and accurate to the best of my knowledge.

                              Name_____________________________________________________
                                              (Print or type)

                              Address___________________________________________________

                              __________________________________________________________

                             Organization________________________________________________

                             Phone_____________________________________________________

                             Signature__________________________________________________

Please submit nomination forms by June 16th to:

West Virginia Public Health Association
Awards Committee
P.O. Box 11635
Charleston, WV 25339-1635

All information will be kept strictly confidential prior to the Thursday evening awards banquet.

 

Hall of Fame Award Guidelines

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