Nomination form for

NZ Young Nurse of the Year 2016

(Closing date for nominations: 8th July 2016)

Please read the award information and assessment document prior to completing this nomination form available at:

SECTION 1

  • Date: ______
  • Nominee’s name: ______
  • Nominee’s date of birth: ______
  • Nominee’s contact number: ______
  • Nominee’s email address: ______
  • Nominee’s current postal address:
  • Nominee’s NZ nursing registration number: ______

(Check on Nursing Council’s website if unsure )

  • Is the nominee a member of NZNO? Yes/No

(Nominee must be a member of NZNO to be eligible for the award)

SECTION 2

  • Nominee’s current and last two previous area’s of work (if applicable) as a nurse:

Current: ______

Previous ______Previous ______

  • When did the nominee begin working as a nurse in NZ? ______
  • When did the nominee commence work in their current area? ______

SECTION 3

.

  • Nominator’s name: ______
  • Nominator’s profession and area of work: ______
  • Your NZ nursing registration number (if applicable): ______
  • Your contact number: ______
  • Your email address: ______
  • Your current postal address:
  • Please specify how you know the nurse you are nominating:

Please note that you may be contacted by the judging panel for further information regarding this nomination.

SECTION 4

Please specify in 500 words or lesshow the nurse you are nominating demonstrates commitment and passion to nursing beyond the every day expectations of a nurse. This may include how the nurse:

-Shows compassion or courage beyond what is expected in their role as a nurse.

-Has improved care/health outcomes for their patients through their commitment to care, leadership, research or quality processes.

-Has overcome major challenges to deliver exceptional care.

(Box will expand as you type)

SECTION 5

Second nominator verifying the accuracy of the nomination information

Name:______

Contact telephone:______

Verification declaration:

I ______, declare that I have read the information contained within this nomination form and that it is an accurate description of the nurse’s practice. I also verify that the nurse is under 31 years of age as at 31 December 2016.

Signature:______

Date:______

SECTION 7

Nominee acknowledgement

In accepting this nomination for the Young Nurse of the Year Award, the nominee agrees to the following:

  1. That I may be contacted to provide further information as part of the assessment process.
  1. That 50% of any cash prize received from NZNO will be used exclusively for further education or professional development.
  1. That if successful, I will be available for the 2017 judging panel;
  1. That my name, photo, achievements and any amount awarded may be published;
  1. That I may be contacted by the co-editors of Kai Tiaki or other member of staff at NZNO for publicity purposes;

I agree to the conditions outlined in points one through four above and declare the contents of this application form to be a true and correct record.

Signature: ______Date: ______

Please send your completed nomination forms to:

Anne Bainbridge

NZNO

PO Box 2128

Wellington 6140

Email:

Closing date for nominations

July 8th 2016.

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