2015 Fabulous Five Award Nomination
Now is the time! Honor a nurse!
Use this form to nominate a nurse for the 2015 TNA District 5 Fabulous Five Nurses Award.
Please email the application to
president@tna5.org
NO LATER THAN
Monday, March 9, 2015
Midnight, CST
Or Mail the application to
TNA District 5 Fab 5 Nomination
P.O. Box 49476
Austin, TX 78765
POSTMARKED NO LATER THAN
Monday, March 9, 2015
If you have questions or problems, send an email to TNA5@tna5.org
Eligibility Requirements:
1. Legal resident of TNA District 5 area (Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays,
Lee, Llano, Travis, Williamson) U.S. Citizen or Alien with U.S. Permanent Resident
Status/Alien Registration Number) or work in TNA District 5
2. Any RN with an active license
o RN - Registered Nurse
o RN/APN - Registered Nurse with Advanced Practice Recognition
o RN/LVN Dual License: Licensed Vocational Nurse and Registered Nurse
o Volunteer Retired Registered Nurse
.Please provide the following background information
Nominee name
Nominee home address
Home phone number
Work phone number
Email address
Nominee's employer
Employer address
Supervisor
Supervisor work phone
Supervisor email address
Nominator name
Nominator phone number
Nominator email address
Nom #: _____________
Date received: _____________
Revised 2/9/2016
For Official Use
Texas Nurses Association, District 5
Fabulous Five Application 2015 (page 2)
Nominee’s position/job title
What is his or her job title? Give brief description of job duties, length of time in position, etc.
(Please limit this portion to 250 words.)
Reason for nomination
Describe how the nominee meets each of the following criteria.
Give specific examples of each.
(Please limit this portion to 500 words.)
1. Leadership Qualities: - improves quality of care; commitment to excellence in nursing practice, education;
committee involvement
.
2. Service to the community – voluntarily participates in community efforts; active in nursing professional
organizations
3. Role model – positive professional influence, mentoring relationships with peers; promoting and
maintaining excellence in nursing practice; practices excellent customer service
4. Compassionate caregiver - makes a special connection with the patient and family; works well with
healthcare team to meet patient and family needs; positive communication skills with co-workers and
patients; respects other personalities and cultures; readily provides assistance to others
5. Significant contributions to the profession – professional development
No additional supporting materials are required or permitted.