Brief Nomination

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Brief Nomination

The Robert Wood Johnson Foundation Community Health Leaders

The Robert Wood Johnson Foundation Community Health Leaders (CHL) honors 10 outstanding and largely unrecognized individuals each year who have overcome daunting odds to expand access to health care and social services to underserved populations in communities across the United States. The CHL award aims to elevate the work of these unsung heroes through enhanced recognition, technical assistance and leadership development opportunities.

Ten awards in the amount of $125,000 will be made for the 2010 cycle. Each new CHL receives $20,000 as a personal gift in recognition of their accomplishments and $105,000 goes to benefit an organization the leader designates.

We are aware that many health professionals serve vulnerable populations. For the CHL award, we are seeking individuals who distinguish themselves because of their extraordinary contributions to their community, beyond the requirements of their job.

High ranking health care employees, senior level officials and development professionals are not likely to be competitive candidates. Nominations from development and public relations departments or from professional grantwriters will not be accepted.

We cannot accept nominations from current or past CHL. However, RWJF grant recipients are encouraged to serve as nominators for possible CHL. A nominee may not nominate her/himself or be a relative of the nominator. Neither can the nominator nor nominee be staff, related to a staff member, or serve on the Board of Directors of the Robert Wood Johnson Foundation.

Does your nominee meet all of the criteria for CHL? Please complete the following checklist (* denotes required field throughout):

Shows innovation in starting or enhancing a grassroots initiative which improves health or health care in their community*

Nominee meets this criterion

Is in mid-career with a three to 10 year record of accomplishment*

Nominee meets this criterion

Has not received significant national recognition for their work*

Nominee meets this criterion

Is a citizen or permanent resident of the United States or its territories by the date full nominations are due*

Nominee meets this criterion

Is affiliated with a public or nonprofit organization that is tax-exempt under Section 501(c)3 of the Internal Revenue Code*

Nominee meets this criterion

Before completing the Brief Nomination, please carefully review the CHL Call for Nominations online.

Nominations should originate from people who personally know the candidate and their work. The nominator must be the one to complete the Brief Nomination and if selected to move on in the process, must also be the person responsible for submitting the information for Stage 2 of the full nomination.

RWJF will notify the nominator if their candidate is selected to continue to Stage 2. Instructions for completing the full nomination will be sent at this time. For more information on the program and nomination requirements please contact:

Helen Dundas, administrative coordinator
Robert Wood Johnson Foundation Community Health Leaders
Phone: (609) 627-5809
E-mail:

DATES TO REMEMBER

October 15, 2009 (5 p.m. ET) – Stage 1: Brief Nominations are due.
November 24, 2009 – Applicants are notified if their Brief Nomination was selected to move to Stage 2.
January 8, 2010 (5 p.m. ET) – Stage 2: Full Nominations are due.

Information about YOU, the nominator

First Name*

Last Name*

Title*

Organization*

Address*

City*

State*

Zip Code*

Phone*

Fax*

E-Mail*

Website*

How did you hear about the Community Health Leaders award?*

What is your relationship with the nominee?

How many years have you been acquainted with the nominee?*

Are you directly involved in the nominee's organization?*

Yes

Has this person previously been nominated for a Community Health Leaders award?*

Yes

Information about the NOMINEE

First Name*

Last Name*

Gender

Male
Female

Title*

Organization*

Is this the organization where the candidate is doing the work for which you are seeking the Community Health Leaders award?*

Yes

Address*

City*

State*

Zip Code*

Phone*

Fax*

E-Mail*

Website*

Highest level of education achieved (Check all that apply)*

Ethnicity (Optional)

Issue Area (Check all that apply)

Special Population (Check all that apply)

If the issue is disease specific, please identify the disease below (examples: HIV/AIDS, substance abuse, mental health, terminal illnesses, oral health, etc.)*

Client Ethnicity*

Community Served (Check all that apply)*

Service Location (Check all that apply)*

In 250 words or less, in the field below
1) Tell us how the applicant personally inspires you;
2) Give an example that best demonstrates their exceptional leadership in the community, and
3) Describe the outstanding initiative and/or service the applicant is directing or leading.

Enter statement*

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