2019 WOMEN IN HEALTH RECOGNITION NOMINATION FORM

2019 WOMEN IN HEALTH RECOGNITION
NOMINATION FORM

A strong nominee will be a woman who has significantly and positively impacted the health landscape of Eastern North Carolina while making sure that ALL in our community have their healthcare needs met.

Please complete this form in full and be very detailed. Please submit nominations by April 1, 2019.

To download a printable version of the form, Click Here

Nominee Name (required):

Company/Organization (if applicable):

Nominee Contact Phone Number (required):

Nominee Email (required):

Number of years in health field (if applicable):

Focus in health field (if applicable - ie. Women’s health, research, chronic disease care, etc):

Volunteer experiences/roles:

Leadership Roles:

What impact has the nominee made on the health of the Greater Pitt County community?

What makes this woman a stand out amongst her peers? Be specific & add additional sheets if necessary:

What does this nominee do to strengthen the health landscape and healthcare safety net in our community?

How does this nominee foster collaboration or innovation?

Family/friends/colleagues to contact for more information about this nominee:

Your Name (required):