Use this form to nominate an individual or team at the Black Country Partnership NHS Foundation Trust who you think deserves additional recognition for the contribution they make. If you wish to nominate the same individual/team for another award please complete another nomination form.

Closing date for nominations is Friday 14th February 2014.

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* 1. Name of Individual/Team being nominated:

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* 2. Job Title:

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* 3. Ward/Department:

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* 4. Location:

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* 5. Telephone Number:

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* 6. Please indicate the award you wish to nominate the above individual/team for:

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* 7. Explain why you believe this individual/team should be recognised for the above award:

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* 8. Describe specifically what this individual/team has done to deserve this recognition:

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* 9. Describe the impact and contribution this individual/team has made on others and the service:

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* 10. Our Promise describes the behaviours expected from all our staff. Give an example of how the individual/team may have demonstrated the following behaviours - Being caring and compassionate, Having the courage to take action, Communicating effectively, Treating everyone as an individual and/or Being competent and professional. (Further information is available on www.bcpft.nhs.uk)

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* 11. Nominated By: Your Name

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* 12. Your Job Title (Trust Employees Only):

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* 13. Your Ward/Department (Trust Employees Only):

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* 14. Your Address:

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* 15. Your Telephone Number/Email Address:

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