NOMINATION FOR THE 2006 COUNTYWIDE PUBLIC HEALTH AWARDS
Please provide contact information and answers to the following questions
listed below. The responses must be typewritten (12 point) and no longer than 2
pages. Type as a separate sheet or use this form.
CONTACT INFORMATION:
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Name of Nominee: |
Name of Organization: |
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Job Role in Organization: |
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Address: |
Phone Number/E-mail: |
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Name of Individual Submitting Nomination: |
Name of Organization: |
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Address: |
Phone Number/E-mail: |
BASIS FOR NOMINATION: Answers to the following questions will be used as criteria for determining the award recipients. Please take the time to adequately describe your nominee.
Describe what this person/organization has contributed to public health programs and services.
Describe what makes this nominee’s contribution outstanding, or goes above and beyond what you would expect. Provide specific information regarding the positive impact and tangible results of the nominee’s contribution for the community.
Please explain how the nominee works in collaboration with other partners to strengthen efforts to address the needs of the community.
Please indicate below which award category you would recommend for your nominee: See category descriptions on next page.
___Advocacy ___Leadership ___Partnership ___Prevention ___Volunteer ___Distinguished Service
Return to Lisa Bullard- Cawthorne, Madison Department of Public Health, 210 Martin Luther King Jr. Blvd., Rm 507, Madison, WI 53703, phone: 294-5303, fax: 266-4858,email: lbullardcawthorne@cityofmadison.com OR Amy Vieth, Dane County Division of Public Health, 1202 Northport Drive, Madison, WI 53704, phone: 242-6507, fax: 242-6256, email: vieth@co.dane.wi.us by Wednesday, February 22, 2006.
PUBLIC HEALTH AWARD CATEGORIES
Advocacy
This individual/group has represented a significant public health issue or works on behalf of a specific population.
Leadership
This individual/group has shown outstanding leadership in our community by preventing, promoting, or protecting a public health issue.
Partnership
This individual/group has actively partnered with the local public health agency and other organizations to provide a public health service in our community.
Prevention
This individual/group has provided a primary prevention public health service/program that has made a significant contribution to preventing injury, illness or disease.
Volunteer
This individual/group has provided an outstanding volunteer public health service.
Distinguished Service
This individual/group has demonstrated excellence in public health work over time.