AMERICAN NURSES ASSOCIATION
2012 MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD NOMINATION FORM
[Please PRINT or TYPE]
PART A.
To be completed by nominating C/SNA President/Designee, IMD Chair/Designee, CNPE
Chair/Designee
NAME OF NOMINEE
Title (√)
Ms.
Miss
Mr.
Dr.
Other (specify:
)
Name
(include credentials; the first 5 will be used on
official documents)
NOMINATING OFFICIAL
Name of C/SNA or
(√) IMD, CNPE
IMD
CNPE
Name of Submitting
Official/Designee
Signature of Official/Designee
PART B.
Date:
To be completed by nominee.
NOMINEE’S HOME ADDRESS
Street/Apt.
Address line 2
City: State: Zip:
City:
State:
Zip:
City:
State:
Zip:
Telephone (w/ area code)
Fax Number (w/area code)
E-Mail Address
PRESENT EMPLOYER
Nominee’s Current Title/Position
Employer’s Name
Street
City: State: Zip:
Telephone (w/ area code)
Fax Number (w/area code)
E-Mail Address
MEMBERSHIP INFORMATION
Member of Which C/SNA (name)
Member of IMD
Yes
No
Registered Nurse (√)
Yes
No
Collective Bargaining Eligible (√)
Yes
No
ANA Membership Number
PROFESSIONAL INFORMATION
MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD
AMERICAN NURSES ASSOCIATION
2012 MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD NOMINATION FORM
Page 2 of 4
Staff Nurse (√)
Yes
No (A staff nurse is defined as one who spends the majority of work time in a nonsupervisory, non-managerial capacity and includes one or more of the following: (1) is employed by a health
care institution or agency, (2) whose primary role is a provider of direct patient care, (3) is collective bargaining
eligible under applicable labor law.)
DEMOGRAPHICS
Gender (√)
Race/Ethnic Group (√)
(Indication of “race/ethnic group”, which is used
for affirmative action purposes, is optional.)
Female
Male
American Indian/Alaska Native
Black/African American
Asian
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White (non-Hispanic)
Other (specify:
)
EDUCATION
(Begin with highest degree earned)
DEGREE/DIPLOMA
AREA OF STUDY
YEAR
EDUCATIONAL INSTITUTION
1.
2.
3.
Concise description of nominee being active in the nursing profession and the significant contributions s/he has
made through demonstrated leadership at the local, district, state and national levels.
MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD
AMERICAN NURSES ASSOCIATION
2012 MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD NOMINATION FORM
Page 3 of 4
Nominee’s Name:
Concise description of nominee’s significant contribution to the advancement of professional staff nurses.
Concise description of nominee’s demonstration of quality of care and professional behavior within his/her
practice at the patient’s side.
I hereby certify and agree to be considered a nominee for the Mary Ellen Patton Staff Nurse Leadership Award and
that the contents of this nominee packet are true and accurate to the best of my knowledge.
Nominee’s Signature__________________________________________ Date:
MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD
AMERICAN NURSES ASSOCIATION
2012 MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD NOMINATION FORM
Page 4 of 4
Nominee’s Name:
MARY ELLEN PATTON STAFF NURSE LEADERSHIP AWARD