Excellence in Service Nomination Form

NOTE: All nominations for Caregivers, Team Members, Department Directors, and Community Nurses must be submitted by the Executive Director at the community.

Nominations for Executive Directors must be submitted by a corporate representative (regional or above).

Please avoid the use of acronyms in the nomination.

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* 1. I am nominating a:

Caregiver (includes medication assistants)

Team Member (defined as non-caregiver, non-manager)

Department Director (non-nurse)

Executive Director

Community Nurse (may include department and care directors; EDs not eligible)

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* 2. Region:

Northern California (honorees recognized at CALA’s Spring Conference)

Southern California (honorees recognized at CALA’s Fall Conference)

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* 3. Please provide the following information:

Nominee's First Name

Nominee's Last Name

Nominee's Title (no acronyms)

Community

Your First and Last Name

Your Title (only an executive director or corporate rep can nominate)

Your Email

Your Phone Number

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* 4. How long has the nominee (please specify whether months or years):

Worked for your company? ___ years ___months

Worked in senior living? ___ years ___months

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* 5. In a paragraph, tell us about a specific time when the nominee went above and beyond day-to-day responsibilities and demonstrated an exceptional commitment to residents.

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* 6. In a paragraph, provide a detailed example of actions taken by the nominee that have enhanced residents’ quality of life.

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* 7. In a paragraph, provide a specific example of how the nominee has been a positive influence on residents and/or fellow staff.

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* 8. In a paragraph, describe what you consider to be the nominee's greatest WOW factor. Provide a specific example in which this was demonstrated.

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* 9. In a paragraph, tell us how the nominee has advanced the mission and goals of the community.

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* 10. In a paragraph, describe how the nominee has positively influenced/impacted the overall community culture and/or the community-at-large. Be specific.

By submitting this form, I agree to arrange for a professional photo shoot (if the nominee is chosen) and will provide photos that meet required specifications within 2 weeks from the date of request. I also understand that anything included in the nomination may be represented in a video.