RCN Wales Nurse of the Year awards nomination form

Please note you will not be able to save the form, it must be completed in one go. Therefore please make sure you have the place of work and contact details for both the nominee and the verifier. Please ensure that the reason for nomination does not exceed 500 words. We recommend nominators write the body of their entry in a separate document first, then copy and paste it into the entry form, to avoid the risk of submissions being lost.

Are you a patient thinking of nominating a deserving member of the nursing profession? You will need to seek support from their senior nurse / manager to help guide you on choosing a suitable award category, and to input into the ‘reason for nomination’, to help you evidence how the individual meets the award criteria. Should have any further queries about how a patient can nominate please contact 02920 680746.

When your nomination has been successfully submitted you will receive a confirmation email – if you do not receive this, it means we have not received your nomination. In this case please contact the Nurse of the Year team on 02920 680746 or nurseoftheyearawards@rcn.org.uk to resolve.

Section 1 - Before completing your nomination

Are you nominating as a patient? Yes No Please select the award category you would like to nominate for Advanced and Specialist Nursing Award Care of the Older Person Award Chief Nursing Officer for Wales Award Children and Midwifery Award Community Nursing Award Health Care Support Worker Award Improving Individual and Population Health Award Innovation and Digitalisation in Nursing Award Learning Disabilities and Mental Health Award Lifetime Achievement Award Nurse Education Award Nursing Student Award Primary Care Nursing Award Registered Nurse Adult Award Supporting Education and Learning in Practice Award Supporting Improvement Through Research Award Suzanne Goodall Paediatric Palliative Care Nursing Award Can you confirm that the nominee works in Wales Yes No Is the nominee a Registered Nurse Registered Midwife Health Care Support Worker Student Nurse Student Midwife Specialist Community Public Health Practitioner Is this a Single nomination Joint nomination

(Note: nominations for teams of 3 or more people will not be accepted)

Has the nominee received a similar national award in the last 12 months? (not required for patient nominations) Yes No If yes, please specify the award received Has the nominee consented to this submission? Yes No

Section 2 - Nominee details

First name Last name Is this a joint nomination? Joint nominee first name (joint nominations only) Joint nominee last name (joint nominations only) Address line 1 (not required for patient nominations) Address line 2 (not required for patient nominations) Address line 3 (not required for patient nominations) Town or city (not required for patient nominations) Postcode (not required for patient nominations) Phone number Joint nominee phone number (joint nominations only) Mobile number (not required for patient nominations) Joint nominee mobile number (joint nominations only) (not required for patient nominations) Nominee email

(Note: please only use lower case letters and ensure the email address is correct as they will be sent a summary of the contact information you have provided)

Joint nominee email (joint nominations only)

(Note: please only use lower case letters and ensure the email address is correct as they will be sent a summary of the contact information you have provided)

Job title(s) Employer Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health Board Cwm Taf Morgannwg University Health Board Hywel Dda University Health Board Powys Teaching Health Board Public Health Wales Swansea Bay University Health Board Velindre University NHS Trust Welsh Ambulance Services NHS Trust Welsh Health Specialised Services Committee Higher or Further Education Independent Sector Third Sector Local Authority Other Place of work

Section 3 - Your details (nominator)

First name Last name Address line 1 Address line 2 Address line 3 Town or City Post code Phone number Nominator email (Note: please only use lower case letters and ensure the email address is correct as they will be sent a summary of the contact information you have provided) Job title Employer Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health Board Cwm Taf Morgannwg University Health Board Hywel Dda University Health Board Powys Teaching Health Board Public Health Wales Swansea Bay University Health Board Velindre University NHS Trust Welsh Ambulance Services NHS Trust Welsh Health Specialised Services Committee Higher or Further Education Independent Sector Third Sector Local Authority Other Place of work

Section 4 - Verifier details

First name Last name Address line 1 Address line 2 Town or City Postcode Phone number Verifier email (Note: please only use lower case letters and ensure the email address is correct as they will be sent a summary of the contact information you have provided) Job title Employer Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health Board Cwm Taf Morgannwg University Health Board Hywel Dda University Health Board Powys Teaching Health Board Public Health Wales Swansea Bay University Health Board Velindre University NHS Trust Welsh Ambulance Services NHS Trust Welsh Health Specialised Services Committee Higher or Further Education Independent Sector Third Sector Local Authority Other Place of work

Section 5 - Reason for nomination

Using a maximum of 500 words (the form won’t submit if you exceed this) - please evidence how your nominee meets the award criteria. Judges are looking for a commitment and passion for nursing, above and beyond their role, give specific examples. Remember to use all of your 500 word limit for your submission – the more detailed you are the better so make full use of the word count given to you!

Section 6 - How did you hear about the RCN Wales Nurse of the Year awards?

RCN Website RCN Wales Social Media Employer Colleagues I am a previous nominator or nominee or award winner Local press