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 and Selections Committee may not nominate others for the Great 100. 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 NOMINATION 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, 2017


Nominator Information (Your Information)

Your First Name:
Your Last Name:
Your Phone: --
Your Street Address:
Your City:
Your State:
Your Zip:
Your Email Address:

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

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 - Personal:
Nominee Email Address - Work:
Nominee Job Title:
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 Expiration Date: / /
Nominee Primary Practice Category:   Click here for descriptions of Practice Categories.

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


Nominee Employer:
Other
Nominee Employer Street Address:
Nominee Employer City:
Nominee Employer State: North Carolina
Nominee Employer Zip:

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


Executive Nursing Leadership/Administrator for the nominee's facility(CNO, Dean, Office Manager, Physician)
Executive First Name:
Executive Last Name:
Executive Email Address:
Executive Title:

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


Academic Preparation: (Check Highest Nursing Degree Obtained) Diploma
ADN
BSN
MSN
Doctorate

         (Check Highest Non-Nursing Degree Obtained) Bachelors
Masters
Doctorate
None

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


Years Experience as Registered Nurse: years.

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


Nursing Professional Involvement: Please list professional involvement within the last 5 years below and select role using the drop down box.

            Professional/Committee Involvement: Role:

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


Community Service: Please list Community Service Activities within the last 5 years below and select organization from drop down box.

Activity: Organization:          Frequency:

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


Honors and Awards: Please list the Honors and Awards within the last 5 years below and select organization from drop down box.

   Honor/Award: Presented By:                Type:

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


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  


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

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

For the section below, please GIVE EXAMPLES in the past 5 years 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.)
Limit of 300 words max for this section.


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Demonstrates integrity, honesty and accountability, and functions within their scope of practice.
(No names of people, cities or hospital affiliation, please.)
Limit of 300 words max for this section.


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Displays commitment to patients, families, and colleagues.
(No names of people, cities or hospital affiliation, please.)
Limit of 300 words max for this section.


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Demonstrates caring and assists others to grow and develop.
(No names of people, cities or hospital affiliation, please.)
Limit of 300 words max for this section.


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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.)
Limit of 300 words max for this section.


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Words remaining: 300

If your nominee were chosen, in one sentence what makes this person an outstanding nurse?
(No names of people, cities or hospital affiliation, please.)
Limit of 300 words max for this section.


Word count: 0
Words remaining: 300


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