This form may be typed of legibly handwritten.  Be sure to complete all sections of this nomination form.

I. NOMINEE INFORMATION

Individual or Program Name:

Address: City: State: Zip:

Phone Number: Email:

__________________________________________________________________________________________

II. PERSON/AGENCY MAKING NOMINATION

Name:

Agency (if applicable):

Address: City: State: Zip:

Phone Number: E-Mail:

May CHE reveal your name as the nominator? Yes No

Date: ___________________________________________________________________________________________

Please limit responses to no more than two typed, double spaced pages.

III. DESCRIPTION

A. What health disparity or disparities is this individual or program addressing?

B. What impact has this individual or program achieved in reducing the health disparity(s)?

Thank you!
Please return this form to:
Community Health Endowment of Lincoln
P.O. Box 81309, Lincoln, NE 68501
Or fax to 402/436-4128