Nomination Application

Please make sure your nominee is not a previous Great 100 recipient as this award is a one time only award.

NOMINATION CRITERIA: Current unrestricted RN license actively practicing nursing in North Carolina at time of nomination. Current members of Great 100 Board, Steering and Selection Committees may not be nominated or nominate others. Previous Great 100 recipients may not be nominated. EACH FIELD ON THIS NOMINATION FORM IS CONSIDERED MANDATORY AND YOU WILL NOT BE ABLE TO SUBMIT THIS APPLICATION IF ANY FIELDS ARE INCOMPLETE. If unsure of work experience or work involvement, please consult with the applicant for the information. If you are unsure of any portion of this Nomination Form you will be able to save the information you have completed and return to the Nomination Form at a later time. No curriculum vitae/resumes will be accepted and can not be attached to this nomination form. Upon completion of the Nomination Form you will have the option to print out the final Nomination.

If you are experiencing ANY problems with the online Nomination Form, please feel free to send a detailed email to webmaster@great100.org.

Nomination deadline is Midnight April 15, 2010

Nominator Information (Your Information)

Your First Name:

Your Last Name:

Your Phone:

Your Street Address:

Your City:

Your State:

Your Zip:

Your Email Address:

Nominee Information (Their Information)

Nominee First Name:

Nominee Last Name:

Nominee Phone:

Nominee Work Phone:

Nominee Street Address:

Nominee City:

Nominee State:

Nominee Zip:

Nominee County of Residence:

Nominee Email Address:

Nominee Employer:

Other

Nominee Job Title:

Nominee Employer Street Address:

Nominee Employer City:

Nominee Employer State:

North Carolina

Nominee Employer Zip:

Nominee R.N. License Number:

If NC or SC, must contain 6 numbers. If only 5,
please place a ZERO BEFORE the number. NUMBERS only, no letters please.

Nominee License State:

Nominee License Experation Date:

/ /

Nominee Primary Practice Category:

Other

Academic Preparation: (Check Highest degree obtained)

Diploma
ADN
BSN
MSN
Doctorate
Other

Years Experience as Registered Nurse:

years.

Nursing Professional Involvement: Please list professional involvement below and select role from drop down box.

Professional/Committee Involvement:

Role:

Community Service: Please list Community Service Activities below and select organization from drop down box.

Activity:

Organization:

Honors and Awards: Please list the Honors and Awards and select organization from drop down box.

Honor/Award:

Organization:

Certification Exams (from ANCC or other specialty organization) - Certifications such as ACLS, PALS, NRP, etc should be included in the narrative section below dealing with promoting and advancing their profession.

Certification 1

Certification 2

Certification 3

Certification 4

Certification 5

Tell us why your nominee should be selected as a Great 100 Nurses of NC

For the section below, please GIVE EXAMPLES of how this nominee:

Promotes and advances the profession of nursing in a positive way in the practice setting and/or in the community, and actively seeks ways to support nurses and other health care providers. Certifications and instructor status for ACLS, PALS, NRP, etc should be described in this section.
(No names of people, cities or hospital affiliation, please.)

Demonstrates integrity, honesty and accountability, and functions within their scope of practice.
(No names of people, cities or hospital affiliation, please.)

Displays commitment to patients, families, and colleagues.
(No names of people, cities or hospital affiliation, please.)

Demonstrates caring and assists others to grow and develop.
(No names of people, cities or hospital affiliation, please.)

Radiates energy and enthusiasm, and contributes/makes a difference to overall outcomes in the practice setting.
(No names of people, cities or hospital affiliation, please.)

If your nominee were chosen, in one sentence what makes this person an outstanding nurse?
(No names of people, cities or hospital affiliation, please.)