Site Visit Application - NC Local Health Department Accreditation

Please review the Site Visit Team Operational Guidelines (pdf) before applying to become a Site Visitor.

Have you reviewed the Site Visit Team Operational Guidelines?*

Yes
No

Name*

First Last

Title/Current Job

Official Position Classification

Public Health Agency (if applicable)

Preferred Mailing Address (suitable for express delivery, not PO Box)*

Street Address Address Line 2 City State ZIP Code

Preferred Email

Please provide a personal email if you plan to retire from your agency within the next two years.

Work Phone*

Home Phone

Cell Phone

Fax

Diploma/Degrees/Certifications/etc.

Public Health Specialty

Environmental Health
Public Health Nursing
Public Health Administration
Board of Health

Please provide a short biography describing your history and role in public health.

Have you participated in accreditation as a health department staff member?

Yes
No

References

Please provide two references who can speak well to your ability to succeed as a Site Visitor, including familiarity with your knowledge of the accreditation process.

Reference 1

Name

First Last

Position

Phone

Email

Reference 2

Name

First Last

Position

Phone

Email