HTNYS Trustee Leadership and Advocacy Award Call for Nominations Survey

Healthcare Trustees of New York State (HTNYS) is proud to announce its "Call for Nominations" for its 2012 Trustee Leadership and Advocacy Award, which will be presented at HTNYS' 32nd Annual Conference on September 14, 2012, at The Sagamore in Bolton Landing. This award, formerly presented as two separate awards, has been combined into a single award.
Please complete this form to submit your nomination.

1. Nominee Information (cannot be a current member of the HTNYS Board of Governors):

Nominee Information (cannot be a current member of the HTNYS Board of Governors): Name:
Facility:
Home Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2. Nominator Information (must be a Chair of Board or CEO):

Nominator Information (must be a Chair of Board or CEO): Name:
Title:
E-mail:
Telephone:

3. Facility Contact Person:

Facility Contact Person: Name:
Title:
E-mail:
Telephone:

4. How long has the nominated trustee served on the board?

How long has the nominated trustee served on the board? fewer than four years

five to nine years

10 to 14 years

15 to 19 years

more than 20 years

Comments:

5. Which positions has the nominated trustee held? (Check all that apply.)

Which positions has the nominated trustee held? (Check all that apply.) Chair

Vice Chair

Secretary

Treasurer

Committee Chair (name which committees in Comments section)

Other (please describe in the Comments section)

Comments:

6. Leadership: Please describe one or two specific and noteworthy initiatives or activities over the past several years in which the nominee took a leadership role. Explain the significance of the activity and its benefit to the organization and community.

Leadership: Please describe one or two specific and noteworthy initiatives or activities over the past several years in which the nominee took a leadership role. Explain the significance of the activity and its benefit to the organization and community.

7. Advocacy: Describe the nominee's advocacy role in the health care organization and the community. This may include health care policy-related issues at the local, state, or federal levels; and/or pressing issues of local concern to the health care organization and/or the community. Please mention how the nominee engaged colleagues, community members, elected officials, hospital administration, or others.

Advocacy: Describe the nominee's advocacy role in the health care organization and the community. This may include health care policy-related issues at the local, state, or federal levels; and/or pressing issues of local concern to the health care organization and/or the community. Please mention how the nominee engaged colleagues, community members, elected officials, hospital administration, or others.

8. Please provide a summary of no more than 500 words of the nominee's leadership and advocacy roles on the board, in your health care organization, and in the community. Describe the qualities the nominee possess that make him/her an extraordinary trustee.

Please provide a summary of no more than 500 words of the nominee's leadership and advocacy roles on the board, in your health care organization, and in the community. Describe the qualities the nominee possess that make him/her an extraordinary trustee.

9. Please describe the nominee's other community involvement and how those relationships have assisted in his/her role on the board.

Please describe the nominee's other community involvement and how those relationships have assisted in his/her role on the board.

10. Please include anything else you would like us to know about this candidate.

Please include anything else you would like us to know about this candidate.

Please also e-mail a letter from the chief executive officer or board chair to HTNYS expressing his/her support for this nomination to staylor@hanys.org by 5 p.m. on May 14. In the e-mail subject line please write "2012 Trustee Award Nomination." Please address the letter to Sue Ellen Wagner, Executive Director, Healthcare Trustees of New York State.