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California TB Elimination Heroes Nomination Form
1.
Name and title of person recommending nominee (please print)
Nominator Name: First and Last
Title of Nominator:
Organization:
Phone
Email
2.
Nominee (Individual or Group)
Name
Credentials
Title
Organization
Phone
Email
City/County
3.
TB Elimination heroes criteria, check all that apply:
Initiated or led new TB prevention activity in their community clinic or CBO
Mentored colleagues in TB prevention efforts
Inspired colleagues to initiate TB prevention activities
Supported at risk populations/individuals to access TB prevention services
Facilitated support for current TB patients/high risk individuals
4.
Please be specific as you describe why you are nominating this individual/group. Your description of their TB elimination efforts, when shared during World TB Day 2025, can inspire others to join this movement (~500 words). The 2024 and 2023 TB Elimination Hero descriptions are great
examples
of inspiring nominations.