Application for Arizona’s Nursing “Leadership in Action” Awards
Award Purpose: To recognize nurses currently leading in various capacities throughout the state and who are
committed to continue providing leadership over the next ten years.
Please complete following form to nominate someone (self-nominations are accepted) for Arizona’s Nursing
Leadership in Action award. Recipients will be honored during lunch at the Annual Adda Alexander Conference
sponsored by the Arizona Organization of Nurse Executives on August 19th at the Carefree Conference Center
and Resort. Recipients will receive a complimentary conference registration.
Email a completed nomination form along with a digital picture and current CV of the nominee to
[email protected] with an email subject line of “Leadership in Action”. Deadline: April 30, 2016.
Criteria for Selection of Award Recipient (all must be met)
1. Currently licensed as a Registered Nurse in the state of Arizona, member of a professional nursing organization
and currently hold a Bachelor’s or higher nursing degree.
2. Significantly or uniquely contributes to leadership (does not need to be in a formal leadership role) within the
nursing profession through clinical practice, education and teaching, administrative leadership, research, writing,
publishing, policy involvement, and/or healthcare innovation.
3. Demonstrates leadership in community affairs, nursing professional organizations, and in the growth and
development of others in these areas.
4. Positively promotes and advances the nursing profession in the community (local/global) through volunteerism
and/or outreach efforts.
Nominator Name: ____________________________________________________________________________
(If self-nomination, please list name for letter of reference/support that must be included with the application form)
Preferred Phone: _________________________________ Secondary Phone: ______________________________
Email: _________________________________________________________________________________________
Nominee Name: _________________________________________________________________________________
Address: ________________________________________________ City___________________ Zip_____________
Preferred Phone: _________________________________ Secondary Phone: _______________________________
Email: __________________________________________________________________________________________
Professional Credentials: __________________________________________________________________________
Current Position / Title: ____________________________________________________________________________
Organization: ____________________________________________________________________________________
Address: ________________________________________________ City___________________ Zip______________
2
BASICS:
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Answer all questions on the nomination form.
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Include a letter of reference along with the nomination form if self-nominated
•
Cite specific examples in your answers and address as many of the areas defined in the Criteria for Selection as
possible.
•
Submit by the deadline to be considered
ESSAY:
Maximum of one (1) page, 1” margins, Arial font size 12 pt., single spaced, 500 word limit
1) Describe specific example(s) of significant or unique contributions the Nominee has made to the nursing profession
through leadership in the following ways
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•
•
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Maintains curiosity and eagerness to explore new knowledge and ideas
Promotes nursing leadership as both a science and an art
Considers the impact of nursing decisions on the health care organization as a whole
Serves as a change agent, assisting others in understanding the importance, necessity, impact and process of
change
OR
2) Provide information which describes specific contributions the Nominee has made to the nursing profession by
providing leadership in community affairs, nursing professional organizations and/or has assisted others to grow and
develop in this area in the following ways
•
•
Demonstrates coaching skills such as contributions to developing others in career planning
Creates an environment in which professional and personal growth is an expectation
OR
3) Describe how the Nominee positively promotes and advances the profession of nursing in the community (local/global)
through volunteerism or outreach efforts in the following ways
•
Describe how the nominee positively promotes and advances the profession of nursing in the community (local,
global) through volunteerism or outreach efforts
•
Represents nursing to non-health care constituents within the community
OR
4) Describe involvement in legislative work, or policy development at the state and/or national level related to health care
in the following way
•
Provides consultation to legislative bodies regarding nursing and health care or political action arms of
professional organizations
INTERVIEW:
Finalists will be interviewed by a panel.
Finalists and recipients of the award will be chosen by the Arizona Action Coalition Leadership Taskforce and will be
notified by July 1st .
Here's to the future of nursing in Arizona!
The Arizona Action Coalition, Leadership Taskforce