The Robert J. Greczyn, Jr. Community Health Center Leadership Award

NOMINATION FORM

COMPONENTS:

  1. Award Nominee Profile
  2. Organization Profile
  3. Certification

______

SUBMIT:

Please return the complete application (with attachments) by April 14, 2017before 5:00 pmto:

NCCHCA

Attn: Patricia Hayes

4917 Waters Edge Drive, Suite 165

Raleigh, NC 27606

Phone: (919) 297-0016

Fax: (919) 469-1263

CRITERIA:
  • State and/or national leadership in primary care and public health
  • North Carolina Community Health Center administrator or provider who demonstrates exemplary commitment to the health of North Carolinians
  • Participation in partnerships on critical health care initiatives within community, region or state
  • Forging collaborations within the healthcare safety-net
  • Increasing primary care access through the expansion of high quality community health center services
  • Vision and influence in the development of future public health leaders
  • Commitment to health promotion and the elimination of health disparities
  • Center is financially viable and sustainable*

*Centers may be asked to provide the most recent financial audit or 990 as evidence of financial status.
Please answer every question using the tab key to move through the nomination form. Do not modify this form in any way.

A. NOMINEE PROFILE

Nominee’sName:

Title:

Health Center:

Years with Center:

Years in Current Position:

Phone:

E-mail:

Provide one example of the nominated person’s leadership at the state and/or national level in the arena of primary care and public health.(No more than 1000 characters, including spaces):

Provide one example of how this person has participated inpartnerships on critical health care initiatives within the community, region or state.(No more than 1000 characters, including spaces):

How and in what ways has this person forged collaborations within the healthcare safety-net? (No more than 1000 characters, including spaces):

How has this individual been responsible for increasing primary care access through the expansion of high quality community health center services? (No more than 1000 characters, including spaces):

Describe the individual’s vision and influence in the development of future public health leaders. (No more than 1000 characters, including spaces):

How has this individual demonstrated his/her commitment to health promotion and the elimination of health disparities? (No more than 1000 characters, including spaces):

Letters of support not required but recommended.

Nominator’s Name:

Title:

Organization:

Phone:

E-mail:

Nominator’s Signature: ______Date:

B. ORGANIZATION PROFILE

Legal Name of Organization:

(as listed on organization’s tax determination letter)

Address (Street, City, State and Zip):

County:

Phone Number: Fax Number:

Organization Web Address:

C. CERTIFICATION

We certify to the best of our knowledge that the information contained in this nomination form is accurate and complete.

Board President:

Signature: ______Date:

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