Nominate a Collaborative

Submit a nomination by filling out the form below. Please note the nomination form cannot be saved and completed at a later date. Before you begin, please preview the Collaborative Nomination Form in its entirety to fully answer questions. It is recommended that the nominator complete questions in a word document and edit prior to filling out the below online nomination form.

If you have questions, please contact Samantha Beasley at SBeasley@healthcaregeorgia.org.

    Name*
    Title*
    Organization*
    Address
    City
    State
    Zip Code
    Phone*
    Email*

    Name*
    Title*
    Organization*
    Organization Website
    How long has the collaborative been active?*

    Address
    City
    State
    Zip Code
    Phone
    Email


    1. Why was the collaborative established?*

    2. Describe the collaborative’s purpose, goals, and objectives.*

    3. Describe the roles and responsibilities of each organization involved in the collaborative.*

    4. What projects related to improving the health of Georgians does this collaborative address?*

    5. What impact has the collaborative had in the community? Please include successes and specific results.*

    6. How does this collaborative identify ways for the community to achieve healthy and equitable outcomes for the residents they serve?*

    7. How has the nominated collaborative demonstrated a commitment to Health Equity?*

    Your printed name:
    Date:


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