Immunize Oregon Shot of Hope Award Nomination Form
Please fill the form below to let us know who you think should receive this year's Immunize Oregon Shot of Hope Award and why!
Nominee:
Nominated Person or Practice
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Organization
Position
E-mail
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Phone Number
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-
Area Code
Phone Number
Nominator:
Person submitting the nomination
Full Name
*
First Name
Last Name
Company
*
Position
*
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Nominee Information
Please share details about why your nominee should win the Immunize Oregon Immunization Champion Award. You may select as many categories as fit or choose other. The committee will be evaluating nominees on their relevant work and also the impact of their activities.
Categories:
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Innovation
Dedication to Community Immunity
Collaboration
Program Improvement
Perseverance
Other
Describe your nominee's Immunization related activities
Use this space to tell us about why your nominee should win the award!
Describe the impact of your nominee's immunization related activities
Use this space to tell us the impact your nominee's work has had!
Anything else that we should know about your nominee's immunization related activities?
Use this space to tell us more!
Submit
Should be Empty: