WSNA Hall of Fame 2022 Nomination Form

The Washington State Nurses Association (WSNA) continually seeks ways to encourage all registered nurses to strive for excellence in nursing. The WSNA Hall of Fame is only one of many projects developed by WSNA to support WSNA members who demonstrate the highest standards of their profession.

Criteria: Each nominee must have demonstrated excellence in the areas of patient care, leadership, education, public service, nurse advocacy, heroism, patient advocacy, or clinical practice and for achievements that have affected the health and/or social history of Washington State through sustained, lifelong contributions. The nominees must have been or currently hold membership in WSNA. The nominee may be living or deceased.

To be considered, nominations must include all required documentation to support the award criteria and a photograph of the nominee. The deadline for nominations is November 30, 2021. Nominees will be notified in January 2022. The award winner(s) will be recognized by the Association, family, friends and nursing colleagues at the Hall of Fame Awards event to be held in the March 17, 2022, at the Hotel Interurban in Tukwila.

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* 1. Hall of Fame Nominee

First Name:

Preferred Name if Different:

Last Name:

Credentials:

Address (Street/City/Zip):

Home Phone:

Work Phone:

Fax Number:

Email Address:

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* 2. Nominee’s photo:

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.

Choose File

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* 3. Summarize this nominee’s WSNA membership background including membership dates, offices held and specific WSNA related accomplishments.

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* 4. Describe how this nominee has demonstrated excellence in the areas of patient care, leadership, education, public service, nurse advocacy, heroism, patient advocacy, or clinical practice.

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* 5. Describe how the achievements of this nominee will have ending value to nursing beyond the inductee’s lifetime.

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* 6. Describe how this nominee has demonstrated excellence that affected the health and/or social history of Washington State through sustained, lifelong contributions.

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* 7. Submit a history of the nominee’s professional achievements/peer recognition.

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* 8. Nominee's Employment:

Current Position or Title:

Employer:

Employer's Address (Street/City/Zip):

Employer's Telephone Number:

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* 9. Submitting additional nursing employment background is encouraged to assist in publicizing this nominee, if chosen as an award recipient.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 10. If the nominee is deceased, are there any known living relatives?

Yes

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* 11. Nominee's Relative:

Name of Closest Relative:

Address of Relative (Street/City/Zip):

Relationship to Nominee:

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* 12. Nominator:

Person Submitting Nomination:

Address (Street/City/Zip):

Home Phone:

Work Phone:

Email Address:

Relationship to Nominee: