Heroes in the Home Nomination Survey 2016

The Central West CCAC Heroes in the Home Caregiver Awards program recognizes caregivers both paid and unpaid.

You can nominate a family member, friend, co-worker, community volunteer, personal support worker,

care coordinator, or health care professional. All caregivers both paid and unpaid will be recognized through this program.

It is easy to nominate a special caregiver. Simply take a few minutes to full out the form below.

Nominations close October 30, 2016.

Please note all questions with a star (*) indicate a required field.

Please be aware that personal information is being collected online in a secure manner according to the following survey monkey guidelines: https://www.surveymonkey.net/mp/policy/security/

Question Title

* 1. Nomination submitted by:

Name

Address

City/Town

Province

Postal Code

Email Address

Phone Number

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* 2. Please identify your relationship with the Hero:

Family

Friend

CCAC Staff Member

Service Provider

Health Care Professional

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* 3. **The Hero in the Home I am nominating is:**

Name

Address

City/Town

Province

Postal Code

Email Address

Phone Number

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* 4. What kind of care or support does the hero provide? Please provide some examples of how the hero helps.

*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

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* 5. How does the hero positively impact the life of the individual(s) he/she cares for?

*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

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* 6. Please provide any additional information you would like to share about the hero.

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* 7. **My nominee and I give the Central West Community Care Access Centre consent to use our nomination at the Heroes in the Home event and for future promotions.**

Yes

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* 8. My nominee and I are interested in attending the awards ceremony; please send us an invitation.

Yes

Thank you for nominating a special caregiver.

Please note that all heroes nominated will receive a certificate of recognition and will be honoured during one of our special award ceremonies.
Please complete this form and submit by: October 30, 2016. Ceremony invitations will be sent out in early November.

For more information, or if you have any questions or concerns please call: 905-796-0040 ext. 7756 or visit us online at: www.heroesinthehomecwccac.com

Question Title

* 1. Nomination submitted by:

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* 2. Please identify your relationship with the Hero:

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* 3. The Hero in the Home I am nominating is:

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* 4. What kind of care or support does the hero provide? Please provide some examples of how the hero helps.*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

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* 5. How does the hero positively impact the life of the individual(s) he/she cares for?*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

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* 6. Please provide any additional information you would like to share about the hero.

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* 7. My nominee and I give the Central West Community Care Access Centre consent to use our nomination at the Heroes in the Home event and for future promotions.

Question Title

* 8. My nominee and I are interested in attending the awards ceremony; please send us an invitation.

* 3. **The Hero in the Home I am nominating is:**

* 4. What kind of care or support does the hero provide? Please provide some examples of how the hero helps.

*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

* 5. How does the hero positively impact the life of the individual(s) he/she cares for?

*Please do not enter personal health information such as patient date of birth, address or details regarding care plan.

* 7. **My nominee and I give the Central West Community Care Access Centre consent to use our nomination at the Heroes in the Home event and for future promotions.**