WEST VIRGINIA PUBLIC HEALTH ASSOCIATION

PUBLIC HEALTH AWARDS
NOMINATION FORM

 

1. Name of Person or organization nominated ___________________________________________________

2. Address ______________________________________________________________

3. Contact Person Phone _____________________________________________________

4. Nomination is for:

____ Citizen's Award
____ Public Health Merit Award
____ Organization or Group Award

5. Submitted by (Name) _____________________________________________________

          6. Address _______________________________________________________________________________
 

Please include as much information as possible to assist the awards committee in making their selections

I. Citizens Award or Public Health Merit Award

7. Individual's Background

a. Present title or occupation ___________________________________________

b. Education (schools attended, degrees received/dates received) ____________________

______________________________________________________________
 

______________________________________________________________

______________________________________________________________

c. Employment (past and present, dates, locations) ____________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

d. Professional, civic and social organizations (membership and offices held) ________________

_______________________________________________________________________________

_______________________________________________________________________________

e. Related or significant information (other awards received, hobbies, marital status, publications authored, special achievements, etc.) ________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

II. Organization or Group Award

8. Organization's or group's background:

a. Name of current president or chairperson ______________________________________

b. Address ___________________________________________________________

_________________________________Phone______________________________________

c. Year established__________________________________ Number of Members__________________

d. Area of state served ___________________________________________________

e. Type of organization (local, national, civic, professional, business, youth, religious, voluntary, government, private, etc.)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

f. Explain briefly: accomplishments, awards, citations, recognitions, event and why nomination is being made. When they occurred. Who and how many were affected? What exact changes or benefits resulted? Specific role of individual or group in the accomplishments? Any other pertinent information helpful to the Awards Committee in making their selection on this award.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

(Additional pages may be added if necessary)

 

All nomination forms must be submitted by June 16th to:

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

The committee will greatly appreciate your nomination for these awards. WVPHA is interested in honoring individuals and/or groups that have made public health contributions in West Virginia. All information will be kept strictly confidential.

 

Public Health Awards Guidelines

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