Child Neurology Foundation Excellence in Transition of Care Award 2021: Nomination Form

Please fill out the below sections with information about how and why the person or institution exemplifies best practices and excellence in transition to adult neurology care.

Applications are due September 30, and winners will be notified on or before October 29.

Selected people or institutions will receive a digital badge to put on their website identifying them as recipients of the CNF 2021 Excellence in Transition of Care Award. Individuals will also have the opportunity to share best practices in an interview that highlights their practice.

Please direct questions to jnickrand@childneurologyfoundation.org.

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* 1. What is your contact information?

Name

Email Address

Phone Number

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* 2. What is the contact information of the institution and/or clinician(s) you are nominating? Self-nominations are encouraged.

Name of Nominee *

Institution Name

City/Town

State/Province

Website

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* 3. If you are not nominating yourself, how do you know the nominee?

I'm a coworker

I'm (or someone in my family is) a patient

I'm a friend or family member

Other (please specify)

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* 4. What kind of patients does the nominee serve? Check all that apply.

Child Neurology Patients

Pediatric Patients

Adult Neurology Patients

Adult Internal Medicine Patients

Other (please specify)

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* 5. How does the institution/clinician(s) exemplify best practices in transition of care? (Please no more than 500 words).

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* 6. What resources for patients does the institution/clinician(s) provide for transitioning patients and their families? Please check all that apply.

Toolkits

Workshops/Conferences

Social Activities for Patients with Complex Health Needs

Resources for other aspects of transition (employment, school, living independently, relationships, etc)

Care Coordination with Other Providers

CNF Resources

Other (please specify)

None of the above

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* 7. What resources for clinician education and support does the nominee provide for continuing education and sharing and implementing best practices? Please check all that apply.

Toolkits

Workshops/Conferences

Podcasts

Patient Outreach/Studies

Technical Tools like Software and other Health IT

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* 8. Please share positive feedback about the nominee's success in transition of care. This can include patient testimonials, personal stories, quality metrics and data, or any other information that helps you tell this story. (Please no more than 250 words)

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* 9. What has the nominee done to change practices of the institution or colleagues to promote patient centered transition of care? (Please no more than 250 words)

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* 10. Is there anything else you want CNF to know about the institution/clinician(s) you're nominating?

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* 11. By signing my name below, I verify that everything that I have included is correct and truthful to the best of my knowledge and ability. I am aware that by submitting this to CNF, CNF may reach out to the nominee directly.