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* 1. Please provide the name, jobsite and position of the person filling out this form.

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* 2. Please provide a phone number tht the Awards Committee could use to contact you outside of school hours if we need any further information about this nomination.

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* 3. Is this nomination of a peer, or a self-nomination?
Only one selection.

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* 4. Please provide the seconder's name, jobsite and position.

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* 5. Name(s), jobsite(s) and position(s) of nominee(s) - Please note: if this was a group project, please nominate the leaders or top contributors to the project or activity.

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* 6. Please select the award(s) for which the nomination may be considered.
Check all that apply.

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* 7. What is the name of the project for which you would like to nominate the nominee(s)?

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* 8. Give a very short description of the project. Please mention the goals or outcomes of the activity and explain the reasons that you decided to seek an award for the nominee(s). *Point-form is great.*

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* 9. What is the timeline of this project or activity?

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* 10. Approximately how many educators were impacted by this project? Also, which bargaining groups did they represent? (You can select more than one option.)
Check all that apply.

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* 11. How many students were impacted by this project? (You can choose more than one answer.)
Check all that apply.

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* 12. Did this activity or project have an impact on the community outside of the school?
Only one selection.

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* 13. Did this activity have an impact on more than one region (i.e. Haldimand and Norfolk)?
Only one selection.

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* 14. Is there anything else you would like us to know about the impact of this project?

T