1. Introduction

The Progressive Leadership Award recognizes an alumnus/a of the Wake Forest Nurse Anesthesia Program who demonstrates accomplishment in the nurse anesthesia profession and the potential for continued growth in leadership roles. To fill the gap between student awards and lifetime achievement awards (such as at AANA), this award is intended to recognize an early to mid-career alumnus who demonstrates a pattern of growth in their professional engagement.

The award is bestowed annually, determined by an award committee, based upon nominations received. Please use this form to nominate someone for the progressive leadership award.

NOMINATOR INFORMATION

Question Title

* 1. Your name

Question Title

* 2. Your email address

Question Title

* 3. Relationship to nominee

NOMINEE INFORMATION

Question Title

* 4. Nominee's name

Question Title

* 5. Nominee’s year of graduation (if known)

Question Title

* 6. Phone

Question Title

* 7. Email

Question Title

* 8. Workplace

Question Title

* 9. Please describe or list the nominee’s accomplishments or examples of leadership in nurse anesthesia. Include specifics such as board memberships, state association positions, etc. Community leadership (scout master, etc.) may contribute, but the main focus of the award is on healthcare-related leadership.

Question Title

* 10. Why do you believe that this nominee has potential to continue to develop as a leader in our profession?

T