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Instructions:  In order to nominate a Local Health Department (LHD) for an LHD award, review the LHD Awards Nomination Guide and refer to the guide when completing this nomination survey.  A separate survey should be completed for each nomination.  All nominations are due on Tuesday, October 1, 2019.  The nominations will be reviewed by the LHD Awards Nomination Subcommittee.  If you have any nomination questions, please send the questions to CASNAP-EdTraining@cdph.ca.gov.  Thank you.  

Awards Nominee Information

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* 1. Agency Name

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* 2. Agency Address

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* 3. Agency City, State, Zip

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* 4. Award Category
Please select the appropriate award category for the nomination.  Please be advised that nominations for the Excellence in Program Evaluation and Exceptional Administrative Work categories will be submitted by the LHD Awards Nominations Subcommittee.

 

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* 5. Award Justification
Please provide detailed information on why the LHD, indicated above, is being nominated for the award and how the LHD meets the awards criteria provided in the Nomination Guide.

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* 6. Award Justification (Additional Space)

Nominator Contact Information

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* 7. Name

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* 8. Title

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* 9. Agency Name

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* 10. Agency Address

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* 11. Agency City, State, Zip

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* 12. Email

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* 13. Phone Number

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