RN Nomination for Excellence in Practice Award 2017

Rockland County Nurse Recognition Day

May 11, 2017
Name of Nominee: _______________________________________ Phone: _________________________

Home Address:
____________________________________________________________________________

Affiliating Agency: ________________________________________________________________________

Job Title: ________________________________________________________________________________

Please check one: ( ) STAFF ( ) ADMINISTRATOR (ID# _____________ Awards Committee to complete)

Nomination Submitted By: ________________________________ Work Phone: _____________________

Criteria:
Nominee must be a Registered Nurse practicing in a Rockland County Health Care Facility or Special Group
or Organization (i.e.: including but not limited to a hospital, nursing home, school nurse, community health,
home care, nursing education, mental health, developmental disability facility, medical office, nurse
entrepreneur, or community volunteer). Nominee should be an individual who goes beyond the call of
duty, and demonstrate creative approaches and excellence in nursing practice.
Please, no group nominations INDIVIDUAL NOMINATIONS ONLY. Please note: Nurse Recognition
Day Nomination Committee Members are not eligible. Recipients of the Excellence in Practice Award, can be
nominated, but are not eligible to win if nominated a second time in 10 years.

The nominees name must appear on this FACE SHEET ONLY. In order to ensure objectivity on the part of
the judges do not use the nominees name or work location anywhere else in the application. All nominations
must be typed. Hand written entries will not be accepted.

The judges will rate the nominee on the attached criteria. When responding to each criteria, please number
them accordingly. Tell how the nominee is excellent in each area and give SPECIFIC EXAMPLES.

Upon receipt of nomination, a confirmation e-mail will be sent within 3 working days. Nominations
must be complete and emailed no later than 11:59 PM, Wednesday April 5, 2017 to:
Chair - Nelly Vega-Woo - Dominican College 845-848-6021
Email: nelly.vega-woo@dc.edu
*Note: For clarification or additional information, you can contact a member of the Nurse Recognition Day
Nomination Committee:
Name Facility Phone # /email
Susan Santos A&T Healthcare 845-825-9180
David Spektor Good Samaritan David_Spektor@bshsi.org
Gail Talamini Rockland Co. DOH (retired) gtalamini22@gmail.com
 NO LATE ENTRIES WILL BE ACCEPTED

RN NOMINATION FOR EXCELLENCE IN PRACTICE AWARD

Please answer the following questions, USING SPECIFIC EXAMPLES, to demonstrate why this nominee
is deserving of this award. Please refer to criteria stated in cover page. Do not include CV's or resumes.

Each question is worth a maximum of 4 points.

1. How do you know this nominee?

2. What is the nominees professional role?

3. According to the criteria stated on the cover sheet, why should this nominee win?

4. What has this nominee contributed to nursing?