Nomination Form - Closing 5 pm Friday, 26 April 2019

We encourage nominations from regional, rural and remote areas.

This award recognises an individual who has demonstrated passion and commitment to their field of work as well as excellence in: improving clinical care and practices, providing support and care for people living with a life-limiting illness, improving health outcomes and the patient experience, leading a service, program or project, providing mentorship or motivation. 

Open to paid employees working in the palliative care sector including: nurses, carers, doctors, allied health professionals, aged care workers, administrators, healthcare executives, marketers, researchers, educators, community developers.

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* 1. Details of the Nominee

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* 2. Provide a brief background of the person and the area in which they work

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* 3. Why do you consider this nominee to be a worthy recipient, recognised by this statewide award?

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* 4. How has this nominee demonstrated passion, commitment and excellence to their field of work as outlined in this category?

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* 5. Details of the Nominator

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* 6. Has the nominee granted consent for their nomination?

DECLARATION
I attest that all the information provided on this form is accurate and true to the best of my knowledge.

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* 7. Name

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* 8. Date

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