NOMINATION FORMD C Hounsell Prize

(Neurology)

Please complete ALL sections of the nomination form.

Nomination forms must be submitted on or before Thursday 24 March 2016

Completed nominations should be emailed to NurseMidwifeAwards@adhb.govt.nz

NOMINEE DETAILS (Their details)Full name:

Current role:

Service area:

Email address:

NOMINATOR DETAILS (Your details)Full name:

Service area:

Contact phone number:

Tell us why you are nominating the nurse, please include something of each of the appropriate sections.

Consistently demonstrates excellence in interpersonal skills

Consistently demonstrates compassion

Consistently demonstrates resourcefulness and knowledge and is an inspiration to others in providing care for patients with Neurological conditions

Any other comments

(Maximum word limit - 200 words for each section)