Application Code______

Nomination Form Page: 1

2012 AHCA Awards Program

Nomination Packet

At its 63rd annual convention in Tampa, FL, on October 7-10, AHCA will recognize honorees for their dedication to improving the quality of life of residents and their communities-at-large.

Following are the requirements and nomination forms for the Developmental Disabilities Hero of the Year award.

AHCA’s 2012DD Hero of the Year Award

At the American Health Care Association’s 63rdAnnual Convention and Exposition in Tampa, FL, on October7-10, 2012, AHCA will honor the 2012DD Hero of the Year. The Honoree shall be a person who has shown commitment and dedication in helping people with developmental disabilities.

Eligibility Criteria

AHCA’s 2012DD Hero of the Year award will be presented to a volunteer, family member or member of the community who has touched the lives of individuals with developmental disabilities. A staff person who volunteers additional time is also eligible.

All entries must meet the following criteria:

  • Nominations must be typed and received by AHCA by Monday, May21, 2012;
  • Nominees must be nominated by a member residence and been involved for at least 6 months prior to nomination;
  • Nominee activities must contribute to the emotional, social, and mental well-being of clients.
Selection Criteria

An impartial group will evaluate the nominations in each category based on the following criteria:

  • Nominee’s involvement in activities and overall impact on clients;
  • Nominee’s role in initiating or supporting programs for clients;
  • Nominee’s contacts outside the residence that enhance the image of the long term care community;
  • Nominee’s length and frequency of participation.

Recognition of Winners

To show DD Hero of the Year Honorees how much we, as a profession, value their efforts on behalf of long term care clients, AHCA will sponsor the awards presentation as part of our annual convention in Tampa, Florida, on October 7-10, 2012.AHCA will invite the DD Hero of the Year and one guest to participate in convention activities at AHCA’s expense.

2012DD HERO OF THE YEAR

NOMINATION FORM

Nominee’s Name

Age (If younger than 18) ______

Address

City______State______Zip

Telephone Number of nominee (used only in coordination with the facility)

Email address

Name of Nominating ICF/MR or HCBS waiver home

Address______

City______State______Zip

Telephone Number Total number of beds

Facility Contact & Title

Facility Contact Signature

Please provide the following information about your Honoree:

I.Length of time of active volunteering ______years

II.Frequency of service ______hours per week______hours per month

How many months per year ______

III.Primary Activities

(check those which apply)

Please Comment
_____Visits clients one on one
Leads or organizes craft sessions or
group discussions
_____Facilitates outside activities
_____Assists with personal services
(shopping, grooming, reading)
_____Enhances community experiences
_____Entertains clients (including
musical performance)
_____Provides support for any of the above
(including transportation)
_____Helps with daily living
_____Other (please be specific)

______

Please note: all essays and photos become theproperty of AHCA and will not be returned.

Application Code______

Nomination Form Page: 1

IV.Please describe briefly any programs developed or supported by the nominee.

______

______

______

V.How does the nominee reach out to the clients?

VI.Explain how the nominee conveys a positive outlook about residence life to those in the surrounding community.

VII. Explain how the nominee’s support conveys a positive outlook on the client’s involvement with community life.

  1. In no more than 250 words, explain what makes your nominee special. In your discussion, please address the following questions:

1)In what ways has the nominee helped clients become active members of the residence’s community or the larger local community?

2)What sacrifices have been made by the nominee -- or what special difficulties have been overcome -- that make his or her contributions unique?

3)How have clients or families acknowledged the value of your nominee’s contributions to them?

Please note: all essays and photos become theproperty of AHCA and will not be returned.