Nomination form

Nominee details

The person you are nominating for the award

Name(Required)

Job title(Required)

Department(Required)

Site(Required)

Contact number(Required)

STAFF NOMINATING COLLEAGUES

If you would like to nominate a colleague please complete the 3 questions below. If you are not a staff member, please jump to the patients, carers and visitors section below…

Please briefly outline why you have chosen to nominate this person or team

What nursing qualities were at the forefront of the nomination (care, compassion, courage, competence, communication, commitment)?

Did this action inspire a positive change in your own care delivery or process or in others?

PATIENTS, CARERS AND VISITORS NOMINATING STAFF

Please complete the 3 questions below…

Please briefly describe how this person or team inspired your Nightingale nomination.

How did this action positively affect you or your family or friend who needed nursing care?

What nursing qualities were clearly evident during the time you or your family or friend were being nursed? (care, compassion, courage, competence, communication, commitment)?

Your details

Please provide contact information with your nomination

Name(Required)

First Last

Job title / department(Required)

Email address(Required)

Telephone(Required)

Address

Street Address Address Line 2 Town / City County Postcode Country

Video permission(Required)

Yes

Would you be prepared for us to arrange to record your nomination which could then be played at the award ceremony?

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Nominee details

STAFF NOMINATING COLLEAGUES

PATIENTS, CARERS AND VISITORS NOMINATING STAFF

Your details

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