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NOMINEE INFORMATION
P L E A S E T Y P E or P R I N T L E G I B L Y
Please limit your comments to this form.
Nominee’s Name/Title:
Name of Facility/Place of Employment:
Current Position/Role:
Primary Area of Practice:
Facility Address:
Home Address:
Telephone:
Work E-mail:
Person Nominating Nurse/Title:
Relationship to Nominee:
Supervisor’s Name:
City
State:
City
State:
Fax:
Home E-mail:
Zip:
Zip:
Education:
Institution
Degree Attained
Year
Professional Work History:
Organization
Role
Time Period
List current memberships in professional healthcare-related organizations:
Organization
Office/Position Held (List responsibilities & contributions)
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NOMINEE INFORMATION
Nominee’s Name:
List current certifications:
List only professional certifications (i.e. board certification such as Neonatal Intensive Care Nursing,
Nursing Case Management, etc. Required certifications such as CPR or ACLS or certifications required for licensure (APRN) are not scored.
Do not use acronyms or abbreviations. We cannot score acronyms.
Examples of unacceptable acronyms: RNC-OB (write out as Inpatient Obstetric Nursing; CPN (write out Certified Pediatric Nursing); C-EFM
(write out as Electronic Fetal Monitoring); RN-MC (write out nursing specialty, e.g. Medical Surgical Nursing)
Organizations granting professional board certification include but are not limited to:
International Childbirth Education Association (ICEA)
International Lactation Consultants Association (ICLA)
American College of Nurse-Midwives (ACNM)
American Association of Critical Care Nurses (AACN)
Oncology Nursing Certification Corporation (ONCC)
Orthopedic Nursing Certification Board (ONCB)
American Nurses Credentialing Center (ANCC)
Pediatric Nursing Certification Board (PCNB)
National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC)
List volunteer service (professional and/or community): Outline committee work, leadership activities and other
contributions. Professional volunteer service involves nursing skills (i.e. health screenings, parish nurse, health lectures, etc.) Community
volunteer service examples include coaching, scouting, PTA, church, etc.) . Please limit data to the most recent 5 years.
List professional achievements: Include awards (national, regional, local); business/efficiency improvements; clinical quality
improvements; patient advocacy activities; and scholarly activities (such as presentations, posters, publications). Please limit data to the most
recent 5 years.
Activity
Achievement/Outcome
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Limit data to the most recent five years. Please limit your comments to this page.
Only use nominee’s name on the top line and DO NOT include the name of the agency.
Name of Nominee:
Phonetic Pronunciation of Name:
Your affiliation with nominee:
How do you see the nominee contributing to/standing out in the profession of nursing?
List and describe achievements, outcomes, specific actions that impact the patient and the profession.
I hereby certify that the above information is accurate to the best of my knowledge.
Nominator Signature:
Print Name:
Email Address:
Title:
Telephone: