Name of person completing form - University of Michigan School of 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Contact Information' section. Provide the nominee's contact details, including their address, home and work phone numbers, and email address.
3. In the 'Information about the Activity' section, clearly state the objective or health change created by the nominee's activities. Be specific about how these efforts contribute to community safety.
4. Describe the activities that led to a safer environment in 200 words or less. Focus on impactful actions taken by the nominee.
5. Explain how these activities go beyond normal job responsibilities in 75 words. Highlight any extraordinary efforts made by the individual or organization.
6. Finally, detail how this activity changed the community in up to 100 words. Emphasize positive outcomes and community impact.
7. Enter your name and email address as the submitter before submitting your completed form via email or fax as indicated.

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