CHIA 2017 Awards form On September 27, 2017, Georgians for a Healthy Future will host the third annual Consumer Health Impact Awards. This event will honor those who work towards equitable, affordable access to quality health and health care for all Georgians. We want you to tell us who should be recognized! Submit your award nominations by Friday, June 30, 2017. Question Title * 1. Your name Question Title * 2. Your email address Question Title * 3. Your phone number Question Title * 4. Your organization, if applicable Question Title * 5. For which award are you submitting a nomination? Linda S. Lowe Health Advocacy Award--The Linda Smith Lowe Health Advocacy Award is given each year to an advocate whose exemplary work advances access to quality, affordable health care in Georgia. Nominees can be either professional advocates or volunteer advocates and must place a focus on vulnerable populations in their work and must work to achieve policy change. This award is named in honor of Linda Smith Lowe. Linda has dedicated her career to serving as an advocate on behalf of underserved Georgians who need a voice on health and human services issues. Community Impact Award--The Community Impact Award is given each year to an individual or organization who has made an exceptional contribution to the health of their community in the past year. The impact of this contribution can be either at the individual, local, or state level. Nominees must work with individuals or local organizations to drive advancements in the health of the population served. Nominees may be health care providers, enrollment assisters, health educators, non-profit organizations, or others. The following questions pertain to the person you are nominating for the award. Please complete all questions fully but succinctly. Keep in mind the description and purpose for each award. Question Title * 6. Name of the person you are nominating Question Title * 7. Nominee's email address Question Title * 8. Nominee's phone number Question Title * 9. Nominee's title and organization Question Title * 10. What community does this person serve? (Example: Low-income people in coastal Georgia, Spanish-speaking residents in Atlanta, LGBT community statewide) Question Title * 11. Why are you nominating this person for this award? Question Title * 12. What makes this person different from others who do similar work? Question Title * 13. Does this person know that you have nominated them for this award? Yes No If you want to provide GHF with more information about the nominee, please send this information to Laura Colbert, Director of Outreach & Partnerships, at lcolbert@healthyfuturega.org. Thank you very much for your submission! We hope to see you at the Consumer Health Impact Awards on Wednesday, September 27, 2017 at Park Tavern in Atlanta. More information, including sponsorship opportunities, is available at healthyfuturega.org/events.Please press "Done" to complete your nomination. Thank you! Done