Tasmanian Nurses and Midwives Honour Roll Nomination Form · Web view2021/01/21 · Honour Roll...
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Honour Roll Nomination Form Overview Organisations and members of the Tasmanian community are invited to nominate a nurse or midwife that is considered to have made a significant contribution to the nursing or midwifery professions at a local, state, national or international level. Nurses or midwives who were born, trained, or who have worked a significant period of their professional career in Tasmania are eligible for nomination. Posthumous and retiree nominations will be also accepted. Nominations commence on the 29 January 2021 and close at midnight (AEST) on the 26 March 2021. Each nomination should acknowledge a nurse or midwife who has displayed extraordinary professional leadership in any practice domain that significantly contributes to excellence in nursing or midwifery by: Assuming a visionary leadership role in shaping the nursing or midwifery profession locally, nationally or internationally; Delivering exemplary nursing or midwifery service, leadership, research and/or practice through stakeholder engagement and/or delivery of nursing or midwifery care; and/or Demonstrating exceptional integrity, fairness and professionalism. Please take the time to give a clear account of why you think this nurse or midwife deserves to be recognised for this honour. As a guide, consider some of the following questions: In what role(s) or area(s) has the nurse or midwife excelled and why? How has the nurse or midwife demonstrated service worthy of recognition, and why? How has the nurse or midwife’s contribution impacted on the nursing and/or midwifery professions or community in Tasmania, nationally or internationally? What makes the nurse or midwife stand out from others? Explain the broad nature of the nurse or midwife’s influence and associated impact on the profession.
Transcript of Tasmanian Nurses and Midwives Honour Roll Nomination Form · Web view2021/01/21 · Honour Roll...
Honour Roll Nomination FormOverviewOrganisations and members of the Tasmanian community are invited to nominate a nurse or midwife that is considered to have made a significant contribution to the nursing or midwifery professions at a local, state, national or international level. Nurses or midwives who were born, trained, or who have worked a significant period of their professional career in Tasmania are eligible for nomination.
Posthumous and retiree nominations will be also accepted.
Nominations commence on the 29 January 2021 and close at midnight (AEST) on the 26 March 2021.
Each nomination should acknowledge a nurse or midwife who has displayed extraordinary professional leadership in any practice domain that significantly contributes to excellence in nursing or midwifery by:
Assuming a visionary leadership role in shaping the nursing or midwifery profession locally, nationally or internationally;
Delivering exemplary nursing or midwifery service, leadership, research and/or practice through stakeholder engagement and/or delivery of nursing or midwifery care; and/or
Demonstrating exceptional integrity, fairness and professionalism.
Please take the time to give a clear account of why you think this nurse or midwife deserves to be recognised for this honour. As a guide, consider some of the following questions:
In what role(s) or area(s) has the nurse or midwife excelled and why? How has the nurse or midwife demonstrated service worthy of recognition, and
why? How has the nurse or midwife’s contribution impacted on the nursing and/or
midwifery professions or community in Tasmania, nationally or internationally? What makes the nurse or midwife stand out from others? Explain the broad nature of the nurse or midwife’s influence and associated
impact on the profession. Why is the nurse or midwife inspiring to you? Has the nurse or midwife’s contribution been recognised elsewhere (e.g. in the
media, by other awards, professional/interest groups or through local government)?
Completing this Application Form
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Please download this form, complete all sections (adhering to the word count) and save a copy for your records. Once completed applications can be submitted via email to [email protected] An independent judging panel will review all nominations to determine the nominee’s suitability.
Please ensure you have provided all requested information and have included any additional supporting information such as newspaper articles, publications. Testimonials are encouraged.
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The Nurse or Midwife to be Nominated Details
Title: (MR /MS /MRS /MISS/DR/OTHER) Click or tap here to enter text.
First Name(s):
Click or tap here to enter text.
Surname:
Click or tap here to enter text.
Was the nurse or midwife born in Tasmania? (Yes/No) Yes ☐ No ☐
Did the nurse or midwife complete their initial or post graduate training in Tasmania? (Yes / No)
Yes ☐ No ☐If yes, please provide details:Click or tap here to enter text.
Is this nomination submitted posthumously? (Yes / No)
Yes ☐ No ☐If no, then complete the following information.
Work Role: Click or tap here to enter text.
Workplace:
Click or tap here to enter text.
Phone Numbers:
Mobile: Click or tap here to enter text.
Work: Click or tap here to enter text.
Email Address:
Click or tap here to enter text.ALL formal communication will occur by email so please ensure this information is correct
Postal Address: Click or tap here to enter text.
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Address the Following Criteria1. Describe the skills, knowledge and leadership that the nominated nurse or midwife
has demonstrated and how this has shaped the health care system and/or contributed to significant person centred care (approx. 250 words).
25% WeightingClick or tap here to enter text.
2. Describe how the nominated nurse or midwife has demonstrated exemplary professionalism over and above that of their peers, including a commitment to advancing the professions (approx. 250 words).
25% WeightingClick or tap here to enter text.
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3. Describe how the nominated nurse or midwife has demonstrated a exceptional commitment to the ideals and purpose of the nursing or midwifery profession consistently over a significant period of time (approx. 250 words).
25% WeightingClick or tap here to enter text.
4. Describe how the nominated nurse or midwife has promoted the advancement of the profession of nursing or midwifery through political, organisation, academic or community context (approx. 250 words).
25% WeightingClick or tap here to enter text.
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More Information Please enter details for both nominators.
Two nominators are required for the nomination to be accepted. The nominators may be contacted and requested to provide more information if required.
Nominator 1 Details Title: (MR /MS /MRS /MISS/DR/OTHER) Click or tap here to enter text.
First Name(s): Click or tap here to enter text.
Surname: Click or tap here to enter text.
Workplace: (if applicable)
Click or tap here to enter text.
Job Title: Click or tap here to enter text.(if applicable)
Phone Numbers:
Mobile: Click or tap here to enter text.
Work: Click or tap here to enter text.
Email Address:
Click or tap here to enter text.ALL formal communication will occur by email so please ensure this information is correct
Date: Click or tap here to enter text.
Nominator 2 DetailsTitle: (MR /MS /MRS /MISS/DR/OTHER) Click or tap here to enter text.
First Name(s): Click or tap here to enter text.
Surname: Click or tap here to enter text.
Workplace: (if applicable)
Click or tap here to enter text.
Job Title: Click or tap here to enter text.(if applicable)
Phone Numbers:
Mobile: Click or tap here to enter text.
Work: Click or tap here to enter text.
Email Address:
Click or tap here to enter text.ALL formal communication will occur by email so please ensure this information is correct
Date: Click or tap here to enter text.
Application Submission To submit your nomination, please email it to [email protected]
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All enquiries to the Office of the Chief Nurse and Midwife phone: (03) 6166 1570.
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