2019 Health Equity Heroes Nomination Form

Submit this nomination by April 26, 2019. Health Equity Heroes will be notified in late May.

Please provide all this information so we can reach out to the Hero nominee if we have questions for him/her. Take your time and write from the heart. What you share in your own words is the most important factor in advancing a nomination for further consideration. Inspire us with what makes your hero special.

Question Title

* 1. Who are you nominating?

Name *

Organization *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number

Email Address *

Social Media Handle *

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* 2. Why are you nominating this individual or organization? How did you become aware of him/her? Talk about the impact this nominee has had/is having on lives in the community. How is he/she uplifting others? What barriers are they removing?

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* 3. Talk about this individual/organization as an equity partner--how they are building partnerships for equity. Is there a specific accomplishment that stands out?

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* 4. Talk about the people this nominee works with, the challenges they face, what they are accomplishing. Are people healthier for their efforts? Please be specific and include impact/outcomes.

Question Title

* 5. Please tell us about you (the nominator) so we can contact you if we have questions.

Name

Organization

Address

City/Town

State/Province

Email Address

Phone Number

If you have questions, please contact Mary Ann Kozlowski at maryann.kozlowski@improvingoralhealth.com.