Nomination Form

Form Approved
OMB No. 0920-0976
Exp. Date 7/31/2016

Million Hearts® Hypertension Control Champion Nomination

The Nomination Form must be completed in its entirety in one sitting. If you navigate away from the form or close your browser before completing the Nomination Form, the information you entered will be lost. The Nomination Form can be viewed or printed prior to beginning the nomination to assist in completing your entry.

Your nomination is complete when you agree to the assurances by typing your name in the box provided and hit the “Submit Nomination” button at the end of the form.

Nominations that are e-mailed or scanned will not be accepted.

Print or view a PDF of the Nomination Form

Public reporting burden of this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-0976.

* Required Fields

Contact Information (for individual submitting the nomination)

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Nominee information

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Check the boxes which best represents the nominee (You may select more than one)

Nominee Reach and Impact

Sustainable Systems

Please check the button before each sustainable process for providing care in the clinic or healthcare system that is used on a regular basis. Provide a brief description of as many “other” processes or systems as applicable to your practice or health system. You may also add details to many of the systems described below to support the nomination.

Agreement to Participate

Please enter your name below to indicate that you, as the nominee, agree to the following.

If you are not the nominee, please enter your name below assuring that you have consulted with the nominee, and the nominee agrees to the following:

  • All information provided is true and accurate to the best of your knowledge.
  • To participate in a data verification process if selected as a champion.
  • Consent to a background check if selected as a champion.
  • To be recognized by provider or practice name and location if selected, to participate in recognition activities, and to share best practices for the development of publically available resources.
  • To assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.
  • To indemnify the Federal Government against third party claims for damages arising from or related to competition activities.”