APPLICATION TEMPLATE - LEADERSHIP ACHIEVEMENT AWARD
Application Cover Sheet
Category: Leadership Achievement Award
Project title:
Applicant(s):
Name
Job Title
Service/
Directorate/
Profession
Organisation
Email
Address
Telephone
QUALITY IMPROVEMENT AND INNOVATION AWARDS 2013
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APPLICATION TEMPLATE - LEADERSHIP ACHIEVEMENT AWARD
Application Checklist
This checklist is provided for personal use to help ensure that all stages of the
submission process are completed.
Have you included?

Cover sheet (including: project title, category entered, name, address,
phone number, email address of the appropriate person in your service).

The Award Question Template completed for the award that you wish to
enter.

Up to four A4 single-sided pages in Arial 11pt.

Your name and title of the project on each page.

Any additional information supporting your application - appendices,
supplementary material (e.g. PowerPoint presentations) and photographs.
 If you have any questions regarding how to enter the awards please contact
Linda Baxter, CCDHB’s Quality Project Manager, on phone 04 806 0705 or email
linda.baxter@ccdhb.org.nz
Entry deadline:
The deadline for entries is 5.00 pm on Monday 16 September 2013.
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APPLICATION TEMPLATE - LEADERSHIP ACHIEVEMENT AWARD
Leadership Achievement Award
Leadership achievement nominee:
Please tell us the name of your Leadership Achievement nominee, including their position, length of
service and their leadership responsibilities.
How do they model leadership?
How does this person demonstrate leadership? What are the qualities they exemplify? How does this
person encourage others to make the most of themselves?
Impact/effectiveness:
What examples can you give of the impact and/or effectiveness of this leader? How have they made
a difference to their workplace or profession? How has this affected health outcomes in Capital and
Coast’s community? How has this impacted in reducing disparities? How has this leader influenced
or impacted you?
Note: The person being nominated for the Leadership Achievement Award must
authorise their nomination. Please complete the details below and attach to your
entry/nomination.
I ______________________________ have been nominated for a Leadership
Achievement Award in the 2013 Quality Improvement and Innovation Awards. I hereby
authorise my entry into the Awards.
Signed ________________________________ Date _______________________
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