Nomination Form : 2022 Lt. Governor's Challenge

Please complete the following information about you, the nominator. Please note: Should your nominee be selected for an award, the Lt. Governor’s Challenge reserves the right to share information on this website and with interested media.

Name:*

First: Last:

Phone:*

Email:*

Affiliation with Nominee:*

Please note: Should the nominee be selected for an award, the Lt. Governor’s Challenge reserves the right to contact them as well as share certain contact information on this website, via social media, and with interested media. We will not share phone numbers or email addresses without the consent of the nominee and/or the nominator.

Name of individual or organization being nominated:*

Primary contact for this organization/individual:*

First Last

Primary contact phone:*

Primary contact email:*

Primary contact’s position at/within this group:*

Please select one of the following to indicate your nominee’s areas of focus:*

Emotional Well-Being (initiatives promote and support the integration of behavioral/mental health services for all Delawareans, eliminating the stigma of these issues and disease, and combatting addiction)

Healthy Living (initiatives focus on increasing access to or improving opportunities for daily physical activity, and access to healthy foods, and/or decreasing initiation or usage of tobacco and/or related products)

Chronic Disease Management and Prevention (initiatives prevent and/or improve health outcomes for those living with or at risk of chronic disease (i.e., cancer, diabetes, heart disease, and stroke)

Mother and Child Health (initiatives support and improve health outcomes of both mother and child from preconception to post-natal care)

Please select one of the following to indicate your nominee’s community category:*

Workplace

School (early learning through higher education)

Community with a Shared Interest (i.e., nonprofit, faith-based)

Town/City/Neighborhood

Individual

Questions in this section give you the opportunity to explain what is unique about your nominee’s initiative as well as the specific impact it is making on the community involved. Please complete every question.

Considering the areas of focus for the Lt. Governor's Challenge, what is the health need within the community and how was it identified? (Define the problem.) (300 words):*

Please describe the goals and objectives of this initiative. How are efforts being measured to document success? (300 words):*

What interventions have been implemented? (Please describe the policy, systems, and/or environmental changes instituted) (300 words):*

What problems are being solved and what are the outcomes as a result of implementation of this initiative (i.e., behavioral change, cultural change, modeled leadership, increased knowledge)? (300 words):*

Are there resources and/or systems in place to continue support of this initiative (staff, monitoring, etc.)? (Please describe.) (300 words):*

Name

This field is for validation purposes and should be left unchanged.

Nomination Form

Important Dates