Healthcare Georgia Foundation

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Community Service

Collaborative Nomination Form

Nominee Information

Name: *

Volunteer Organization Name(s) *

Address *

City *

State *

Zip *

Telephone *

Fax

Email *

Alternate address

Address

City

State

Zip

Telephone

Fax

Email

Nominator Information

Name: *

Title

Volunteer Organization Name(s) *

Address *

City *

State *

Zip *

Telephone *

Fax

Email *

Alternate address

Address

City

State

Zip

Telephone

Fax

Email

Collaborative Award Criteria

Provide a detailed history and description of the collaborative effort. Include goals, objectives, partnerships, etc. *

Describe the roles and responsibilities of the organizations involved in the collaborative.*

What projects related to health and/or health care concerns does this collaborative address? *

What impact has the collaborative had on the community? Be sure to include successes and specific results. *

Does this organization reflect and represent the diversity of the community it serves? *

Describe how the collaborative has been proactive in initiating change to promote better health outcomes in the community it serves. *

Your (Printed) Name *

Date *

Electronic Signature Confirmation *

Once you press submit, this form cannot be revised. Upon submission, you will receive an email confirmation of your nomination.

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