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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 Lisa Medellin, Director of Programs at lmedellin@healthcaregeorgia.org or by phone (404) 653-0990.

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?*


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