Nomination Form

The following criteria will be used to select Public Health Heroes:

Public health efforts make a significant difference in the lives of the people served.
Public health efforts build on individual and community strengths and assets.
Efforts mobilize individuals and community groups to work
in collaboration and cooperation.
Efforts are unique, innovative, or fill an identified gap in a specific community.
Characterized by social justice and a celebration of diversity.

Please be at detailed and specific as possible about the nominee. The information provided will be the sole factor in the review committee’s ranking of nominees. Deadline: Friday, March 5, 2010.

Please fill in all fields below so that we can contact the appropriate person/s.

Your name:
Your contact information:
Address:
City, state, zip code:
Phone:
Email:
Person or group you are nominating:
If nominating a group, please give a contact person:
How can we contact this nominee? Please fill in all fields.
Address:
City, state, zip code:
Phone:
Email:
Category for which you are nominating this person or group (one category per nomination, please):

Multnomah County Employee
Community Person (Josiah Hill Award)
Community-Based Program or Non-Profit Organization
Business/Corporation
Public Health Leadership (John Kitzhaber Award)
Youth (under 19 years of age; Katie Jeans-Gail Award)
Please describe how this person or group promotes health and wellness in our community (limited to about 500 words):

Please describe why you feel this person or group should get a Public Health Heroes Award (limited to about 500 words). Give specific examples:

Updated January 25, 2010