NOMINATION FORM 2016
Healthcare Humanity Awards 2016
OPEN CATEGORY
FOR PRIMARY/ACUTE/TERTIARY/SPECIALTY CENTRES
The Open Category is for all levels of Healthcare Workers regardless of titles, e.g., Doctors,
Nurses, Allied-Health Professionals, Support Staff with direct patient care.
Part A: PARTICULARS OF NOMINEE
Full Name (as in NRIC/Passport)
Telephone
Salutation
(Dr/Prof/Mr/Ms/Mrs/Mdm)
(HP)
(Office)
Email
Designation/Title
Specialisation
Department
Name of Organisation
Part B: PARTICULARS OF NOMINATOR
Full Name of Nominator
Relationship to Nominee
Designation
Telephone
Name of Organisation
(HP)
(Office)
Email
Note: The judging panel may conduct interviews as necessary to assess the nomination.
Part C: PARTICULARS OF REFEREES
1ST Referee
2nd Referee
Full Name of Referee
Full Name of Referee
Relationship to Nominee
Relationship to Nominee
Name of Organisation
Name of Organisation
Telephone
Telephone
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NOMINATION FORM 2016
Email
Email
Part D: DETAILS
Q1. Please provide a brief summary description (between 200 to 1,000 characters) of
the nominee’s daily job.
(Sample Answer: As a Nurse Clinician in Home Ventilation Respiratory Support Services
(HVRSS), Mary manages a caseload of patients who are ventilator-dependent. Being the
patients’ point of contact, she works closely with a multidisciplinary team and continually
updates them on patients’ condition to ensure effective, efficient and coordinated care.
Mary’s daily duties also include collecting and sending patient specimens for lab tests,
tracing lab results, coordinating therapeutic interventions, and following up with doctors to
provide new advice for caregivers. Changing tubes and administering medication for patients
are also part of Mary’s daily tasks. On top of these, she also needs to update case sheets to
keep track of patients’ conditions.)
A1.
Q2. Please describe one particular incident when the nominee exhibited one or all of
these values: Courage, Extraordinary Dedication, Selflessness, Steadfastness in
Ethics, Compassion and Humanity. This incident should be above and beyond the call
of duty of the nominee. If possible, please state the time and occasion of the incident.
(Sample Answer: Since the implementation of the HVRSS, Mary has been very active in
developing materials for caregivers. The HVRSS health booklet drafted by her is currently
awaiting publication. Aware that HVRSS is still in the early stages, Mary is constantly looking
for ways to develop the programme. She is instrumental in networking with overseas
providers and communicating with Home Ventilation Nurses in Newcastle, England, to
improve and develop our HVRSS processes and capabilities.
As the only nurse in HVRSS, Mary works tirelessly with her medical colleagues to explore
ways to improve the process of caring for ventilator-dependent and ventilator-assisted
patients at home despite her heavy workload. She often calls caregivers after working hours
to check on her patients and will not hesitate to provide psychosocial support for patients
and families.
Mary also schedules visits at the convenience of the patient’s family as she understands that
care for ventilator-dependent patients is very demanding in nature. In March 2014, the wife
of a ventilator-dependent patient called Mary at 5.30 p.m. to report that the PEG tube was
leaking from the stoma site. Although it was already past her working hours, Mary still called
the community doctor for help and both of them went down to the patient’s home. Within an
hour of the call, the patient’s PEG tube was changed. Mary’s selflessness and steadfast
dedication saved both the patient and caregiver the hassle of having to travel to the
Emergency Department and related expenses.
Mary is also able to empathise with family members’ anxieties, always making herself
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NOMINATION FORM 2016
available to support grieving families, visiting wakes and providing emotional support for the
families. After the wake, she continues to follow up with caregivers to find out how they are
coping and speaks to social workers to arrange follow-up actions if she sees the need.
Mary embodies the values of this award. Her compassionate spirit, extraordinary dedication
and genuine care for her patients and their families is truly exceptional. She leads by
example in many ways and is an inspiring role model to her colleagues.)
A2.
Q3. Has the nominee volunteered in any humanitarian missions whether at home or
abroad? If so, please describe how the nominee contributed to the mission.
(Sample Answer: Outside her work with HVRSS, Mary is a committed volunteer who is
always willing to sacrifice her personal time to serve the poor and disadvantaged, regardless
of race, religion and nationality. She joined the Rotary Club Singapore on a two-week
medical service trip to a village in Nepal in January 2013 and went to Bangkok for two days
in May 2014 to teach Thai ICU nurses Critical Care Nursing as part of missionary work
organised by Edwards Lifescience.
Mary has also participated actively in the activities of the Motor Neuron Disease (MND)
support group which included educational talks, entertainment and group sharing to help
better educate patients and improve their morale. Like other MND support group volunteers,
Mary regularly involves her family to encourage more solidarity between individuals and
families. On many occasions, she brought her seven-year-old son to participate in MND
activities to engage him in her work and to teach him the values of empathising and
understanding patients’ needs.
In the 2013 Typhoon Haiyan disaster, through liaising with Filipino nurses, Mary also actively
helped and donated clothes to disaster victims. Other than that, she also donates monthly to
the Kidney Dialysis Foundation, Singapore Power Heartware Fund and the Singapore
Children’s Society.)
A3.
Congratulations on completing this form.
Please save the file as a Microsoft Word document according to the following file name
format and email it to your institutional coordinators for collation.
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NOMINATION FORM 2016
[CATEGORY CODES]_[ORGANISATION ABBREVIATED NAME]_[FULL NAME OF
NOMINEE]
CATEGORY CODES:
OPEN
: OP
ILTC
: IL
CAREGIVER : CA
VOLUNTEER : VO
ORGANISATION ABBREVIATED NAME:
E.g., SGH, BVH, SAMH, AMKTHK
Example:
The nominee’s name is Mary Tan and the nomination is submitted by Tan Tock Seng
Hospital. Therefore the file name should read:
OP_TTSH_Mary Tan
Closing Date: 21 Dec 2015
Thank you for your nomination!
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