Awards Nomination Form

CDC/DHPE Health Education and Health Promotion Awards

Awards Description and Criteria | Awards Nomination Guidelines | Awards Nomination Form | Previous Award Recipients

Submit nominations by May 23, 2008 (on-line preferred)or mail/fax to DHPE.

Download the form in Word Format [Word File, 26 Kb]

Add a new Award Candidate

Fill in the information below to add an Award Candidate.

Nominee First Name	Nominee Last Name
Nominee Title	Nominee E-mail
Nominee Phone	Nominee State
	Choose a State -------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands

Award(s) Category: Select the following award for which you would like to nominate the above named person. See Award Descriptions and Criteria for additional information on each award category. Leadership Award State/Community Collaboration Award Evans/Muneoka Award Health Promotion Medal of Excellence Health Promotion & Education Advocacy Award
Award Category
Choose an Award -------------- Leadership Award State/Community Collaboration Award Evans/Muneoka Award Health Promotion Medal of Excellence Health Promotion & Education Advocacy Award
Please describe the nominee's contributions in each of the following areas. Descriptions should not exceed 250 words under each item. Describe the activities and level of effort of the individual or group which merit the award for which they are being nominated. If an individual is being nominated, describe the position they held while performing this work and any relevant publications. Describe the results or impact of the nominee's work. What were identified outcomes? Describe how this work was important or significant to health promotion/health education field or community.
Nominee's Contributions
To be completed by person filling out this form:

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Referred by Title	Referred by E-mail Address
Referred by Phone
Referred by Address
Referred by City
Referred by State	Choose a State -------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands
Referred by Zip Code

Once you click the "Add New Award Button", you will receive confirmation of receipt of nomination. The nominee will also receive a congratulatory note for nomination.