Awards Nomination Form

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1. Individual Award

a. Criteria:

i. PNP must be working in and a resident of Minnesota
ii. PNP must be a graduate from a formal education program for the preparation of nurse practitioners
iii. The individual must have made a significant contribution to the region in promoting health care of children and families in one or more of the following areas:

1. health care delivery
2. education
3. research
4. administration promotion of the PNP role

b. Information to be submitted by the nominating person should include:

i. Statements describing the nominee’s contributions, accomplishments or leadership activities as they relate to the PNP award.
ii. Name of person being nominated
iii. Address
iv. Home phone number
v. Place and address of employment
vi. Work phone number

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2. Organizational Award

a. Criteria:

i. An organization will be honored for promoting the health and well being of children in the state of Minnesota. It can be a for-profit or non-profit organization that has a mission focusing on children. It may also be an organization which is not child-focused but which holds events or provides services that recognize developmental, physical, psychosocial or emotional needs of children and families.
ii. Information to be submitted by the nominating person should include:

1. Statements about the organization’s contribution
2. Name, address, and phone number of organization
3. If possible, a contact person at the organization

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PNP making the nomination:______________________________

Name of Nominee:____________________________

Home Phone:__________________

Address:______________________________________________

Work Phone:__________________

Please submit this form along with your submission information to:

Lisa Dornick

4853 15th Ave S.

Minneapolis, MN 55417

 

DUE DATE FOR SUBMISSION: NO LATER THAN March 15th

Awards will be given at the Spring Conference & the persons making the nomination will present the award.