Online Steering Committee Member Nomination Form

All questions require a response and will be shared with the MPCC Membership as part of ballot material during the election of Steering Committee Members.

Name of nominee organization: *

Name of nominee organization's representative and title: *

Will the organization provide its representative the time and commitment to serve a three-year term?: *

Yes

If other than a self-nomination, has the organization and representative assented to be nominated?:

Yes

N/A

Current Member of Steering Committee: *

Yes

Year became a MPCC Member: *

What is the organization's interest, commitment, and experience with primary care improvement?: *

What has been the organization's experience with the MPCC (e.g., served on MPCC committees, attended mtgs., provided resources?: *

Submitted by: *

Date: *