2026 Outstanding Rural Health Organization Nomination Form Survey

1.Nominee Information

Organization Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

2.Organization Administrator/Primary Contact(Required.)

Name

Title

Email Address

Phone Number

3.Rural Geographic Area(s) affected by nominee’s work

4.Organization Information/Resources

Optional: Upload any materials you would like to include that describe the organization..

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5.Organization Website (if applicable)

6.Nominee’s contribution to rural healthcare.

Please attach a word or PDF document with a 300-500 narrative describing the nominee’s involvement in rural health, the significance of the organization's contribution to rural health, and how the rural area and residents have benefited from the organization..

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