HEALTHCARE LEADERSHIP AWARDS
2015 Nomination Form
The Los Angeles Business Journal is proud to announce the 2016 Healthcare Leadership Awards.
We are accepting nominations for individuals and organizations that have made strides in helping
Angelenos receive better healthcare. In order for patients to receive superior care, all parts of the
organization must be operating efficiently and effectively. We will recognize leaders that make an
impact to both lines: those leading the frontlines of healthcare and those protecting the bottom
lines.
NOMINATION PROCESS:
We want to hear from you! Nomination forms (along with a digital photo) must be completed
and emailed by Friday, February 15, 2016 to be considered. All sections of the form must be
completed for consideration by the selection committee. Award categories will be determined by
selection committee once all nominations have been received. Nomination FORMS must be
submitted as a WORD DOCUMENT.
Please email nomination forms to: Jennifer Hakim at jhakim@socalbusinessjournals.com
2016 AWARD CATEGORIES
INDIVIDUAL AWARDS:
Hospital CEO
Hospital Executive (CMO, CNO, CRO, etc)
Insurance CEO
Medical Group CEO
Healthcare Manager
Research Executive
Lifetime Achievement
ORGANIZATION AWARDS:
Community Clinic
Community Outreach Program
Hospital/Medical Center
Institutional/Educational Program
Safety Net Provider
THE AWARDS LUNCHEON:
All nominees will be notified approximately three to four weeks prior to the awards luncheon.
Winners will be announced at the 2016 Healthcare Leadership Forum & Awards on April 15, 2016.
The Los Angeles Business Journal will publish a special supplement highlighting the honorees and
finalists within the April 25, 2016 edition.
NOMINATION DEADLINE:
Friday, February 15, 2016
Healthcare Leadership Awards
2016 Nomination Form
SECTION I: GENERAL INFORMATION – ALL fields must be completed.
Please provide us with the follow contact information so that we may reach you with any questions
and/or to discuss the project/nominee.
NOMINATOR NAME (YOUR NAME)
COMPANY
TITLE
COMPANY ADDRESS
CITY, STATE, ZIP
PHONE
EMAIL ADDRESS (REQUIRED)
COMPANY WEBSITE
WHO ARE YOU NOMINATING? ALL fields must be completed for the Nominee.
NOMINEE NAME
COMPANY
TITLE
COMPANY ADDRESS
CITY, STATE ZIP
PHONE
EMAIL ADDRESS (REQUIRED)
YEARS WITH THE COMPANY
COLLEGE/ UNIVERSITY ATTENDED
DEGREE ATTAINED
Healthcare Leadership Awards
2016 Nomination Form
SECTION II: AWARD CATEGORIES FOR CONSIDERATION
You may select no more than TWO categories for consideration.
INDIVIDUAL AWARD CATEGORIES
HEALTHCARE MANAGER
HOSPITAL CEO
HOSPITAL EXECUTIVE (CMO, CNO, CRO, etc.)
INSURANCE EXECUTIVE (CEO, PRESIDENT, etc.)
LIFETIME ACHIEVEMENT
MEDICAL GROUP CEO
RESEARCH EXECUTIVE
OTHER (WRITE IN)
_______________________________________
ORGANIZATION/TEAM AWARD CATEGORIES
COMMUNITY CLINIC
COMMUNITY OUTREACH PROGRAM
HOSPITAL OR MEDICAL CENTER
INSTITUTIONAL OR EDUCATIONAL PROGRAM
SAFETY NET PROVIDER
OTHER (WRITE IN)
_______________________________________
Healthcare Leadership Awards
2016 Nomination Form
*** SECTION III IS FOR INDIVIDUAL NOMINATIONS ONLY.
ORGANIZATION AND TEAM AWARD CATEGORIES PLEASE SKIP TO SECTION IV. ***
SECTION III. TELL US YOUR NOMINEE’S STORY!
For each of the following sections, please use the space provided (or on a separate page) to tell us
about the nominee by answering each question. This is your chance to explain to our judges why
the nominee should be considered for this prestigious award. Please provide detail.
SECTION III - A: DESCRIPTION OF RESPONSIBILITIES (minimum of 300 words required)
Please provide a description of the nominee’s day to day responsibilities within the healthcare
industry. If the nominee manages a staff, what is the size of the staff and what is the staff’s role?
Describe the nominee’s daily interaction with patients (if any).
***** SECTION III CONTINUED ON NEXT PAGE *****
Healthcare Leadership Awards
2016 Nomination Form
SECTION III - B: HISTORY (minimum of 300 words required)
How long has the nominee been working in his/her current position? Has the nominee’s position
changed and/or increased in responsibility since originally hired? How long has the nominee been
working in the healthcare industry as a whole?
***** SECTION III CONTINUED ON NEXT PAGE *****
Healthcare Leadership Awards
2016 Nomination Form
SECTION III - C: COMMITMENT TO EXCELLENCE (minimum of 300 words required)
Please provide a detailed description of what makes the nominee a candidate for a Healthcare
Leadership Award. What contributions has this person/company/team made to the advancement
of healthcare in Los Angeles? How has the nominee excelled above and beyond their job
responsibilities and/or their colleagues?
***** SECTION III CONTINUED ON NEXT PAGE *****
Healthcare Leadership Awards
2016 Nomination Form
SECTION III - D: COMMUNITY (minimum of 100 words required)
Does this nominee actively participate in community programs outside of his/her job
responsibilities? Does the nominee donate time to charities and/or nonprofit organizations
(including boards/committees)?
SECTION III - E: COMMUNITY/BUSINESS REFERENCE
Please include one reference outside of his/her company that would recommend him/her for this
award. Examples: a longstanding patient, nonprofit or civic leader, service professional or
healthcare leader.
Name:__________________________________________________________________________
Title:___________________________________________________________________________
Company:_______________________________________________________________________
Phone:__________________________________________________________________________
Email:___________________________________________________________________________
**** END OF INDIVIDUAL NOMINATION FORM – NEXT PAGE IS FOR ORGANIZATIONS ONLY ****
Healthcare Leadership Awards
2016 Nomination Form
*** SECTION IV IS FOR ORGANIZATION/TEAM AWARDS ONLY ***
SECTION IV. TELL US YOUR NOMINEE’S STORY!
For the categories of Community Clinic, Community Outreach Program, Hospital/Medical Center,
Institutional/Education Program, and Safety Net Provider – please use the follow TWO PAGES to tell
us about the nominee. Please use this space (or separate pages) to provide DETAILS on what the
nominated organization is doing to be worthy of this recognition. (Minimum of 300 words required)
Things to consider: How has the organization and its people gone above and beyond its core
competencies? What impact has the organization had on helping to ensure that Angelenos receive
better healthcare? What types of services does the organization provide and how are they different
or unique from the services that others provide? How has leadership within the organization
helped to improve or expand the services it provides? Are there unique policies, procedures or
other metrics used to help efficiency and effectiveness? In short, what makes this organization
more deserving of this award than any other?
*****END OF NOMINATION FORM *****