Nominations Form 

 The Paterson-Passaic County-Bergen County HIV Health Services Planning Council, also known as the Bergen-Passaic TGA, recognizes that the struggle to improve the lives of PLWH is a team approach. The Paterson-Passaic County-Bergen County HIV Health Services Planning Council would like to take the opportunity to acknowledge individuals and organizations, who have demonstrated a commitment to creating a tremendous positive impact. 

Culturally Competent 
Empowers Consumer
Strong Advocate 

Award Categories 

Medical Services 
- Commitment to patients, includes a relationship of mutual respect
- Creates an environment that fosters the exchange of knowledge and experience 

Physicians & Nurses 
- Creates an environment where consumers are partners in treatment 

Religious & Civic 
- Creates an environment whereby HIV stigma is challenged 
- Illustrates courage in the fight against HIV 

Social (Service Agency) 
- Does not discriminate just because a person is HIV positive 
- Provides an exceptional level of service to the community 

Individual (one from each county) 
- Makes a positive impact on the HIV-affected and infected community 
- Provides an exceptional level of humanitarian concern to the community

Social Service Personnel 
- Effective and current knowledge of benefits system and willingness to share with consumers 
- Effective and current knowledge of HIV and its impact on consumers 

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* 2. Name of Individual or Organization

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* 3. Address

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* 4. City, State & Zip 

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* 5. Phone

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* 6. Email

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* 7. Using the criteria and categories described, please describe why you feel the person or organization is worthy of special recognition.

Please Note: All categories need not be awarded every year. The Steering Committee will act as the selection committee. A nominee must have had a direct impact on the Bergen-Passaic TGA.