Nomination Form

The Fort Drum Regional Health Planning Organization (FDRHPO) and North Country Health Compass Partners are seeking nominations for the 2018 Community Health Hero award. This is your opportunity to recognize an individual who has demonstrated outstanding community service toward the improvement of physical, mental, or emotional health and wellness. 
   
Your nominee can be anyone
 - working, volunteering or residing in Jefferson, Lewis, or St. Lawrence County.
 - striving to improve health and wellness [neighbor, loved-one, healthcare provider, peer advocate, public servant, etc.]
 - demonstrating an exceptional level of compassion, effort, and achievement.
        
Community members may submit one nomination for consideration. Please nominate an individual based upon his or her contribution in Jefferson, Lewis, or St. Lawrence County. One "Hero" will be selected in each of the three counties (3 awards total). Volunteers from The North Country Health Compass Partners will select award recipients from the list of nominees. The 2018 recipients from each county will be announced on National Rural Health Day - November 15th.
    
Your nomination helps raise awareness of the health challenges faced in Northern New York, and the heroes who fight to improve the health of their community. Thank you.

Question Title

* 1. Your information.

Question Title

* 2. Who are you nominating for the 2018 Community Health Hero award?

Question Title

* 3. Is this person employed? If so, please provide employer information.

Question Title

* 5. Describe how this person has impacted the health and wellness of community members. If applicable, include the type and level of impact as well as the number of people affected.

Question Title

* 6. Describe the level of time commitment: hours per week, number of months, number of years, etc.

Question Title

* 7. If applicable, describe how this person's efforts were unique or outstanding?
[The optional questions below are to help guide your response.]
  • Were there significant challenges to overcome?
  • Have lives significantly changed as a result of this person's efforts?
  • Has this person inspired your community in a significant way?
  • Did this person initiate or lead these efforts?
  • Have these efforts resulted in a sustained or replicable volunteer program?
  • Have these efforts influenced public policy in any way?

Deadline for nominations is September 7th, 2018.

Any Questions? 
Email pfontana@fdrhpo.org

T