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.

Question Title

* 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 (EDs not eligible)

Question Title

* 2. Region:

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

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

Question Title

* 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

Question Title

* 4. How long has the nominee:

Worked for your company? (months or years)

Worked in senior living? (months or years)

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

* 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.

Question Title

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

Question Title

* 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.