Awards Nomination Form

Please consider the nominee for the following award: (Pick one)*

Distinguished Achievement Award

Matthew Lee Girvin Award

Nominator:

Full Name:*

Title

Organization:

Phone:*

Email Address:*

Nominee:

Full Name:*

Title:*

Organization:*

Phone:*

Email Address:*

Please answer the below questions about the nominee to the best of your ability:

Professional Achievement:*

Please describe the nominee’s professional achievements as they relate to their public health career. Include a description of the nominee’s work, key activities and work history. Also consider sharing projects for which they are directly responsible or for which they oversee; the uniqueness of their work; the populations most impacted by this work; and the likelihood that this work will continue to impact the future of public health.

Dedication to Public Health Ideals:*

Please describe how the nominee’s work has contributed to advancing or improving the field of public health. Include any volunteer experiences.

Awards / Recognition:*

Please share any awards or recognition the nominee has received as a result of their contributions to public health. Recognition can be in the form of a physical award, verbal accolades or positive media attention.

In addition to completing this form, nominators are also encouraged to provide the nominee’s resume or CV, letters of support and biographical information about the nominee's relevant education, background, interests, past awards, or other recognition for work in public health.

Resume or CV and Letters of Support*

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