PUBLIC HEALTH NURSE OF THE
YEAR
Nomination Form
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Please provide as much information as possible per section to facilitate the selection process. Focus on professional accomplishments and community commitment, and less on personal attributes. Please be as anonymous as possible when completing application. Refer to generic pronouns and terms (he/she, church, school, etc.) whenever possible, beyond the initial page, and less on direct references to identity. I wish to nominate the following person for West Virginia Public Health Association Nursing Section Public Health Nurse of the Year: Name:______________________________________________________________________________________________ Address:____________________________________________________________________________________________ ___________________________________________________________________________________________________ Telephone:__________________________________________________________________________________________ County of employment:_______________________________________________________________________________ Person submitting nomination: I certify the enclosed statements are true and accurate to the best of my knowledge.
Name:_____________________________________________________________________________________________ Address:___________________________________________________________________________________________ __________________________________________________________________________________________________ Telephone:___________________________________________________________________ County of employment:_________________________________________________________ Signature:___________________________________________________________________ Date:_______________________________________________________________________ (Additional pages may be added if necessary) All nominees should make every effort to attend the Annual Fall Conference, as should the person or persons submitting the nomination. All information will be kept strictly confidential prior to the award. However, nominees will be notified at time of nomination to allow for adjustment of their schedule. 1. Number of years as a Public Health Nurse:_______________________________________ 2. Number of years in the West Virginia Public Health Association (include offices held, accomplishments, contributions, etc.):______________________________________________________________________________________________ __________________________________________________________________________________________________ 3. Numbers of years in the West Virginia Public Health Association-Nursing Section (include offices held, accomplishments, contributions, etc.):_________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. List and briefly explain involvement in any other professional organization:__________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 5. Explain briefly any community and/or nonprofessional involvement:_______________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 6. List any awards, honors, and recognitions received:___________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 7. Focusing on professional accomplishment and community commitment, describe why you believe this nurse deserves to be recognized as the West Virginia Public Health Association Nursing Section’s Public Health Nurse of the Year:__________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ |