Healthcare Trustees of New York State (HTNYS) is proud to announce a "Call for Nominations" for its 2018 Trustee Leadership and Advocacy Award, which will be presented at HTNYS' Annual Conference on Saturday, September 15, at The Saratoga Hilton in Saratoga Springs.

Please complete this form to submit your nomination by June 26 (5 p.m.) to Healthcare Trustees of New York State.  Thank you.

Nominee information (Nominees cannot be a current member of the HTNYS Board of Governors):

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

Nominator information (Nominators must be board chairs or chief executive officers):

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* 2. Nominator information (Nominators must be board chairs or chief executive officers):

Facility Contact Person:

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* 3. Facility Contact Person:

How long has the nominated trustee served on the hospital or health system board?

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* 4. How long has the nominated trustee served on the hospital or health system board?

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

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

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

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

Advocacy: Describe the nominee's advocacy role in the community.  Please focus on the nominee's commitment to the community and his or her role in promoting collaborative relationships and/or joint ventures with others in the community.  Advocacy activities can include: healthcare policy-related issues at the local, state, or federal levels; and/or pressing issues of local concern to the healthcare organization and/or community.

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* 7. Advocacy: Describe the nominee's advocacy role in the community.  Please focus on the nominee's commitment to the community and his or her role in promoting collaborative relationships and/or joint ventures with others in the community.  Advocacy activities can include: healthcare policy-related issues at the local, state, or federal levels; and/or pressing issues of local concern to the healthcare organization and/or community.

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

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

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

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

Please include additional information you would like the review panel to know about this candidate.

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* 10. Please include additional information you would like the review panel to know about this candidate.

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