2010 RN OF THE YEAR AWARD
NOMINATION FORM
Nomination Deadline: January 29, 2010
1.
Nominee:
Name:
Professional Title:
Phone:
2.
Award Category:
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3.
Work:
Home:
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Clinical Practice (majority of position spent in direct patient/client care)
Education
Administration
Advanced Practice (Master’s Degree required)
Submitted By:
Name:
Phone:
4.
Work:
Home:
Nominee’s Qualification:
Describe contribution of candidate as a role model in one or more of the following areas as
applicable: ***Indicate what specific contribution (demonstrate candidate’s excellence) the
individual has done in both clinical and professional practice areas.
a.
Significant contribution to the health care of patients/clients: (This is particularly important for
the Clinical Practice category.)
b.
Significant contribution to patient/client education:
c.
Significant contribution to nursing education:
d.
Significant contribution to healthcare administration:
e.
Significant contribution to nursing research:
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5.
Community Service:
Describe significant contribution(s) to the community by involvement in one or more of the
following:
a.
Civic:
b.
Church:
c.
Nursing Activities and/or Organizations (Describe role as member or leader):
Please email the application as an attachment to Mykel Newton at
mnewton@childrenscentralcal.org or mailstop SC59.
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