FORM 1

Republic of the PhilippinesDepartment of Health

OFFICE OF THE SECRETARY

Bayani ng Kalusugan AwardNomination Form

To: BAYANI NG KALUSUGAN AWARD TECHNICAL WORKING GROUPFrom:       Date:      

We respectfully nominate       to the Bayani ng Kalusugan Award for:

Service Delivery Governance Health Technology

Health Financing Health Information and Research

Attached are documents to support the nomination.

      (Signature over Printed Name)

Nominator’s InformationDesignation / Institution:       Mobile Number:       Office Telephone Number:      

E-mail address:      

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 Direct Line: 711-9501Fax: 743-1829; 743-1786 ● URL: http://www.doh.gov.ph; e-mail: osec@doh.gov.ph