Form: Quarterly Award Nomination - North Country Tobacco Treatment Network
Dear North Country Tobacco Treatment Network members,

Do you know a North Country tobacco treatment specialist or partner who has made strides, big or small, to overcome barriers to tobacco treatment access? The North Country Healthy Heart Network would like to celebrate and share their work at the next Quarterly Gathering. You are welcome to nominate yourself and/or someone else. Feel free to nominate multiple people. A committee of Network members will review nominations (let us know if you wish to join it!)

Awardee(s) will be notified 5 days prior to the gathering, and welcomed to share a brief summary of their challenges and solutions if they wish, to further peer-to-peer learning and support. Nominations are due 7 days prior to the gathering.

Thank you for your participation and for your passion for tobacco treatment!

-- Stefanie

For more information, please contact me
Stefanie Miller
Tobacco Cessation Project Manager
North Country Healthy Heart Network
(518) 891-5855
smiller@heartnetwork.org

Today's date *
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Your name (person filling out form) *
Your answer
Your email (person filling out form) *
Your answer
Name of nominee *
Your answer
Email of nominee *
Your answer
Organization of nominee *
Your answer
Is there a challenge that the nominee has faced? Please describe the challenge and solution, if known (it is ok if you do not have specific examples) *
Your answer
What characteristics to you admire about the nominee? *
Your answer
Is there a story you can share here about the nominee to illustrate your recommendation? (optional)
Your answer
Thank you for participating! May we quote selections from your application in a press release, if nominee is selected? *
Anything you would like to add about the nominee or this process?
Your answer
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