Texas Nurses Association, District 5

Fabulous Five Award Nomination Now is the time! Honor a nurse!

Use this form to nominate a nurse for the 2016 TNA District 5 Fabulous Five Nurses Award.

Please email the application to [email protected]

NO LATER THAN Friday, March 31, 2016 Midnight, CST

Or Mail the application to TNA District 5 Fab 5 Nomination P.O. Box 49476 Austin, TX 78765

POSTMARKED NO LATER THAN Friday, March 31, 2016 Midnight, CST

If you have questions or problems, send an email to [email protected] Eligibility Requirements: 1. Legal resident of TNA District 5 area (Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Travis, Williamson) U.S. Citizen or Alien with U.S. Permanent Resident Status/Alien Registration Number) or work in TNA District 5 2. Any RN with an active license o RN - Registered Nurse o RN/APN - Registered Nurse with Advanced Practice Recognition o RN/LVN Dual License: Licensed Vocational Nurse and Registered Nurse o Volunteer Retired Registered Nurse Please provide the following background information Nominee name Nominee home address Home phone number Work phone number Email address Nominee's employer Employer address Supervisor Supervisor work phone Supervisor email address Nominator name Nominator phone number Nominator email address

Nominee’s position/job title

What is his or her job title? Give brief description of job duties, length of time in position, etc.

Revised 4/4/2018 Nom #: ______Date received: ______For Official Use (Please limit this portion to 250 words)

Reason for nomination

Describe how the nominee meets each of the following criteria. Give specific examples of each.

(Please limit this portion to 500 words)

1. Leadership Qualities: - improves quality of care; commitment to excellence in nursing practice, education; committee involvement .

2. Service to the community – voluntarily participates in community efforts; active in nursing professional organizations

3. Role model – positive professional influence, mentoring relationships with peers; promoting and maintaining excellence in nursing practice; practices excellent customer service

4. Compassionate caregiver - makes a special connection with the patient and family; works well with healthcare team to meet patient and family needs; positive communication skills with co-workers and patients; respects other personalities and cultures; readily provides assistance to others

5. Significant contributions to the profession – professional development

No additional supporting materials are required or permitted.