Awards of Excellence 2023 Nomination Form

The nomination deadline has been extended to March 31, 2023

BEFORE YOU BEGIN:

IMPORTANT: This Nomination Form must be completed in a single session. You will not be able to partially fill it out and return at a later time.

Therefore, please complete the following before you begin this Nomination Form:

1) Read the Award’s Eligibility Criteria.

2) Decide which one of the four Awards best describes the person you want to nominate.

3) Ask two additional people to be Sponsors for this nomination and get their contact information to complete this Nomination Form.

Question Title

* 1. Nominator Information (This is YOU. The Nominator is the primary sponsor and contact person.)

Full Name

Place of Employment

Address

Town

Province

Postal Code

CLPNA Registration number (if applicable)

Relationship to Nominee

Email Address

Phone Number

Question Title

* 2. Nominee Information (This is the person you are nominating for an Award.)

Name

Place of Employment

Address

City/Town

Province

Postal Code

Graduation Year:

CLPNA Registration number (if LPN)

Daytime Phone Number

Email Address

Question Title

* 3. FOR LPN NOMINEES ONLY: I can confirm the LPN I'm nominating:

Holds an Active Practice Permit from CLPNA

Is in good standing with CLPNA

Resides in Alberta

Has actively practiced for at least five years

Is currently employed as an LPN

Question Title

* 4. Sponsor 1 (For the Interprofessional Award, this should be another health discipline in the nominee’s work environment.)

Full Name

CLPNA Registration number (if LPN)

Relationship to Nominee

Email address

Daytime work number

Question Title

* 5. Sponsor 2

Full Name

CLPNA Registration number (if LPN)

Relationship to Nominee

Email address

Daytime work number

Question Title

* 6. Please choose the award category

PAT FREDRICKSON EXCELLENCE IN LEADERSHIP AWARD (LPN)

RITA MCGREGOR EXCELLENCE IN NURSING EDUCATION / PRECEPTOR AWARD (LPN)

LAURA CRAWFORD EXCELLENCE IN NURSING PRACTICE AWARD (LPN)

INTERPROFESSIONAL DEVELOPMENT AWARD (NON-LPN)