Health Equity Hero Nomination Form
Please fill the form below to nominate an individual who has dedicated their career and work to advancing health equity and creating real, lasting impact to the lives of marginalized patient populations. You are welcome to nominate yourself. Chosen nominees will be considered for our Health Equity Heroes Series on individuals who have championed health equity.
Nominated Person (feel free to nominate yourself!)
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First Name
Last Name
Company or Organization
*
Title/Position
*
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Nominator:
Person submitting the nomination. If self-nomination, please skip this section.
Full Name
First Name
Last Name
Company
Position
E-mail
Phone Number
-
Area Code
Phone Number
Nominee Information
Please indicate details about your nomination
Reasons why you are nominating yourself or someone else as a health equity hero?
*
Feel free to input links, examples, and any information that would provide greater context.
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