2020 Health Equity Heroes Nomination Form

Nominations are due by May 29, 2020. Health Equity Heroes will be notified by end of June, 2020.

Please complete the seven questions below. 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.

*Asterisk = Required question

Eligible Candidates

The 2020 Hero is any person or team working to enable more equitable health outcomes and one or more of the following:

Helps maintain access and continuity of care in these challenging times
- Providing emergency care in dental deserts
- Adopting telehealth and integrating it for the longer-term health of vulnerable patients
- Collaborating with other health providers for holistic care while nonemergency care is on hold
Demonstrates flexibility and out-of-the-box thinking in response to the pandemic crisis, such as
- Unusual partnerships
- Unique ways to communicate or engage
Brings oral health into the broader public health conversation, such as

Changing public perception about oral health and disparities
Promoting prevention and health literacy in culturally appropriate ways

Question Title

* 1. Who are you nominating?
(Please provide the following information so we can reach out to the nominee if we have questions for him/her).

Nominee Name *

Organization Legal Name *

Email *

Phone *

Address *

City *

State *

ZIP *

Website

Social Media Handles

For each of the following questions, please limit your answers to no more than 500 words.

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* 2. Why: Why are you nominating this individual/organization for DentaQuest's Health Equity Heroes Class of 2020?

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* 3. What: Is there a specific accomplishment(s) that stands out?

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* 4. How: How is your nominee uplifting others? What barriers are they removing?

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* 5. Who: Talk about the people/population the nominee works with and the challenges they face. Are people healthier for your nominee’s efforts? Please be specific and include impact/outcomes.

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* 6. Please provide a brief biography for the nominee.

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* 7. How can we get in contact with you if we have questions?

Nominator Name

Date

Organization

Phone

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

Question Title

* 1. Who are you nominating? (Please provide the following information so we can reach out to the nominee if we have questions for him/her).

Question Title

* 2. Why: Why are you nominating this individual/organization for DentaQuest's Health Equity Heroes Class of 2020?

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* 3. What: Is there a specific accomplishment(s) that stands out?

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* 4. How: How is your nominee uplifting others? What barriers are they removing?

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* 5. Who: Talk about the people/population the nominee works with and the challenges they face. Are people healthier for your nominee’s efforts? Please be specific and include impact/outcomes.

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* 6. Please provide a brief biography for the nominee.

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* 7. How can we get in contact with you if we have questions?

* 1. Who are you nominating?
(Please provide the following information so we can reach out to the nominee if we have questions for him/her).