2021 Public Health Partnership Award Nomination Form
Complete the form below to nominate an award recipient in the field of Public Health and/or Environmental Health in New York State. The designated award nominee does not have to be a member of NYSPHA. Submission Deadline is April 5th, 2021
Your Name
*
First Name
Last Name
Your Title
Your Organization
*
Contact Number
*
E-mail
*
example@example.com
Tell us about the person or organization you are nominating for this award:
Nominee Name
First Name
Last Name
Title and Credentials
*
Nominee Email
example@example.com
Nominee Phone Number
Please enter a valid phone number.
If nominating an organization or Local Health Department (LHD), please include Organization or LHD name and contact information.
Organization, Address, Phone Number, Website
Choose an award for this individual or organization
Citation for Outstanding Leadership in Public Health in New York State (individual)
Citation for Outstanding Leadership in Public Health in New York State (organization)
Hermann M. Briggs Memorial Medal and Certificate
Legislator of the Year Award
Membership Award
New York State Local Health Department of the Year Award
Environmental Health Leadership Award
Tell us why this individual or organization should be recognized with this award in public health or environmental health. Please include a short bio, and any public or weblinks to support accomplishments of individual nominees. (please note, we may ask for references if needed).
Additional Comments:
Submit
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