PLEASE INSERT UNIQUE REFERENCE NUMBER (URN): ______

The Queen's Nursing Institute

Application for the title of Queen’s Nurse

PATIENTCONTRIBUTOR

[Date]

Dear [Patient/Client name]

I am applying for the title of Queen’s Nurse.

The Queen’s Nursing Instituteoffers this title as a way of recognising nurses,and health visitors working in the community who make a special contribution to the care of their patients or clients, and in so doing earn their trust and respect.

As part of my application a number of patients/clients that I care for, and my manager, will be asked to comment on their experience of my work.

I would like to ask you to be one of the patients I choose. I hope you will not mind filling in the enclosed form and posting/emailing it back directly to the QNI by [insert closing date].

You are under no obligation to complete the form if you choose not to, and this will not affect your care in anyway.

Thanking you in anticipation.

Yours sincerely

The Queen's Nursing Institute

Application for the title of Queen’s Nurse

PATIENT/CLIENT CONTRIBUTOR

The applicant
Name of Applicant
Applicant’s unique reference number (URN)
Patient/client’s details
Name
(required)
Main postal address
(required)
Postcode
Telephone number
(required) / Mobile
Email
(required if you have an email address)

This sheet will be removed before your application is forwarded to the Assessment Panel, please do not add any other information to this page.

Data protection statement

Your privacy is important to us, and we will NOT pass your details to any third party. The Queen's Nursing Institute will only use the information provided on this form if we wish to contact you to verify the information you have provided. We may want to use your comments anonymously in our literature to illustrate the qualities of a Queen’s Nurse.

Please tick the box if you do NOT want us to do this

How long have you known the applicant? Please tick

3-6 months / 6 months - 1 year / 1-2 years / 2-5 years

Do you feel confident in your nurse’s knowledge/ability to provide the care you need?

Yes
No
Comment

Do you feel confident in your nurse’s ability to give you the advice and information you require?

Yes
No
Comment

Do you feel reassured by your nurse?

Yes
No
Comment

Do you feel able to ask your nurse questions, voice your concerns and talk about your care?

Yes
No
Comment

Does your nurse tailor your care to your personal circumstances and consult you about what you want?

Yes
No
Comment

Does your nurse give you the time you feel you need?

Yes
No
Comment

Do you feel your nurse shows you respect?

Yes
No
Comment
A Queen’s Nurse is someone who is highly skilled in their field of community nursing and provides you with a feeling of well-being, of service and respect. Someone whom you feel has a real interest in your well-being and who you feel really cares for you.

Does this describe your nurse?

Yes
No
Comment

Thank you for taking the time to complete this form.

Please return your form directly to the QNI

Preferably by email to by post to:

The Administrator

The Queen’s Nursing Institute

1A Henrietta Place

London

W1G 0LZ

.

Patient/client contributor form- updated January 2018Page 1