Call for Nominations s1

HIV/AIDS CERTIFIED NURSE OF THE YEAR AWARD HIV/AIDS Nursing Certification Board

Please consider nominating yourself or an ACRN/AACRN colleague for the HIV/AIDS Nursing Certification Board, HIV/AIDS Certified Nurse of the Year Award.

To be considered as a candidate for HIV/AIDS Certified Nurse of the Year Award by the HIV/AIDS Nursing Certification Board, the candidate must meet the following criteria:

1. Currently certified as an HIV/AIDS Certified Registered Nurse, or an Advanced AIDS Certified Registered Nurse 2. Membership in the Association of Nurses in AIDS Care 3. Demonstrated excellence in HIV/AIDS nursing 4. Demonstrated leadership in ANAC and HIV/AIDS nursing activities 5. Demonstrated involvement in HIV/AIDS community activities 6. Fosters advancement of HIV/AIDS Certified Registered Nurses through sharing of expertise

Type of Nomination:  self-nomination  nomination of an ACRN/AACRN colleague

Demographic Information of HIV/AIDS Certified Nurse of the Year Nominee:

Address

City State Zip code

Phone: home work

Fax Email ANAC Membership #

ACRN/AACRN since Will candidate be attending ANAC conference?

Demographic Information of Person Nominating the Above Individual for HIV/AIDS Certified Nurse of the Year

 Information is the same as above since this is a self-nomination

If the information is different than above, please complete the following information so that we may contact you for your more information, if necessary.

Address

City State Zip code

Phone: home work

Fax Email

Form Approved by HANCB BOD, 17 June 2002 Professional Experience of HIV/AIDS Certified Nurse of the Year Candidate

Please include a copy of the nominee’s resume with this application.

Number of years practicing HIV/AIDS nursing:

Highest Degree Obtained

 Diploma  Associates Degree  BSN  BA/BS in another field  MSN/MN  MA/MS in another field  PhD/DNSc  DNP  EdD

Other Certifications Held by Nominee

 C  CS  NP  CCRN  CEN  OCN/AOCN  Other 

Current Position

Title Agency

On a separate sheet of paper, please highlight the following information about the nominated candidate for the HIV/AIDS Certified Nurse of the Year Award.

1. What is the nominee’s professional experience in HIV/AIDS nursing? 2. How has the candidate demonstrated clinical excellence in HIV/AIDS nursing? 3. What activities has the candidate been involved in that demonstrate leadership and Commitment to professionalism in HIV/AIDS nursing? 4. How has the candidate promoted certification as an HIV/AIDS Certified Registered Nurse?

Signature of Nominating Person Date

By July 31, 2017, please submit the completed nomination forms, including the candidate’s resume, via mail, email or fax:

HIV/AIDS Nursing Certification Board 11230 Cleveland Ave NW #986 Uniontown OH 44685 (800) 260-6780 email: [email protected] fax: (202) 540-9094

NOTE: All current members of the HANCB and ANAC Board of Directors are Ineligible to Apply. Receipt of the Award does not include financial sponsorship to attend the ANAC Conference or the ACRN Luncheon to receive the award. The Award Winner will receive a cash prize of $500 and a plaque.

Form Approved by HANCB BOD, 17 June 2002