NAHUC AWARD NOMINATION FORM

Per NAHUC Policy 2106, All Nomination Forms are to be sent to the NAHUC  Office on or before April 1.  Nominations should be in narrative form of not more than four pages and must contain  supportive evidence for criteria

Category: Institutional Provider

Institutional Provider Criteria: Must be a current institutional provider and all fees to NAHUC must be current.  Must provide health unit coordinator education through continuing education or a formal course.

 1.    Facility Name  ___________________________________________________________

        Address________________________________________________________________

        City _________________________________ State ______  Zip code ______________

        Phone_____________________________ E-mail ______________________________

        Designated Educator Name ________________________________________________

2.                   How has the facility contributed to the recognition and support of NAHUC and the health unit coordinator profession?  Submit on separate sheet.

3.         Additional comments..  Submit on separate sheet.

4.         Name, address, and phone of person submitting the nomination:

            _____________________________________________________________________

            _____________________________________________________________________

            _____________________________________________________________________

            _____________________________________________________________________

Complete the form above and submit with narrative answers to questions 2 and 3.

Mail or fax to NAHUC prior to April 1.

NAHUC
1947 Madron Road
Rockford, IL  61107-1716
Fax: 815-633-4438