Black Nurse of the Year Nomination Form

The Black Nurses Association of Greater Washington, DC Area is seeking nominations for the Annual Black Nurse of the Year Award. The Award will be granted to a Black nurse who has made a significant contribution to the health of the Black community of the Greater Washington, DC area.

General Information and Instructions:

The nominee must be a Black registered nurse or a licensed practical nurse who has lived in the greater Washington, DC, area for a minimum of three (3) years and is a US citizen.
All information is confidential and will not be returned.
A recent photo must accompany the completed application.
All applicants will be informed of the decision of the Awards Committee.
A cover letter should include the name of the person or organization making the nomination and a contact telephone number

To nominate an individual for this award, please complete (typed only) the application form describing how the individual meets the award criteria. Additional consideration will be given to applicants who are members of the Black Nurses Association. Resumes will not be accepted. All applications must be received by October 15^th.

Applications may be sent electronically by completing our online form below or by mailing the pdf version to:

Black Nurses Association of Greater Washington, DC
Attn: BNA Program Committee Chairperson
Post Office Box 55285
Washington, DC 20040
contactus@bnaofgwdca.org

BLACK NURSE OF THE YEAR AWARD NOMINATION FORM

Submission Date:

Name:

Address:

City: State: Zip Code:

Telephone (Home): (Work):

FAX: Email Address:

Years in the greater Washington DC area:

Member of Black Nurses of Greater Washington Dc Area, Inc: Yes No

Nursing License No: State: Expiration Date:

Certification: Yes No Expiration Date:

Specialty/Organization:

Educational Preparation

Nursing Program:

Institution and Completion Date

NLN Approved: Yes No

Additional Educaton (include current enrollment)

Institution	Degree	Completion Date

Employment History

List positions held for the last five (5) years, including length of time. Start with current position.

Institution/Agency	Position	Dates
1.
2.
3.
4.
5.

Affiliations/Activities

List professional, civic and/or church offices held, committees, etc. locally, regionally and/or nationally in the last five (5) years.

Organization	Office	Dates

Honors And Awards

Entries should be limited to the last five (5) years.

Name of Award	Institution/Organization	Date

Instructions: Describe activities, which address the categories, provided below. The applicant must respond to the first three (3) categories (Use a blank sheet of paper and follow the format provided).

1.	Nursing Education Impacts the professional practice of nursing and the health of the Black community through excellence in teaching, Demonstrates expertise/leadership in nursing education through various publications, presentations and honors, Engages in teaching/learning activities that improve the quality and quantity of persons entering/choosing nursing as a career, Provides leadership in nursing education through recruitment, mentoring and other activities supportive of career advancement of Blacks in nursing, Develops and/or presents workshops and other educational activities that promote consumer knowledge and understanding of health requirements.

2.	Community Service (Volunteer Activities Only) Collaborates with community organizations, schools and churches to deliver community based services such as health fairs; Demonstrates leadership in the delivery of health services and health education to groups of consumers within their own communities and neighborhoods; Coordinates nursing volunteer activities such as childhood and elder (influenza and pneumococcal) immunizations, hypertension screening, glucose and cholesterol screenings.

3.	Nursing Service/Practice Provides evidence of recognition as an expert clinician by peers (at all levels), and other health related practitioners; Possesses clinical expertise/competence in one or more nursing clinical areas of practice such as maternal/child, community health, psychiatric and medical-surgical nursing; Demonstrates advanced practice/clinical competence by attaining professional certification; Demonstrates creative approaches to the delivery of quality health care; Serves as preceptor for beginning nurses.

Optional Categories: The Applicant may address one or more of the following categories for additional consideration by the Awards Committee (Use a blank sheet of paper and follow the format provided).

4.	Nursing Research Conducts research in nursing to increase the body of knowledge about the health requirements of Black consumers; Publishes and analyzes research, individually, and/or in collaboration with others; Disseminates research results that advance the health of Black consumers.
5.	Legislative/Political Activites (Health Focused) Participates in activities that educate legislators and politicians regarding laws and policies that impact the health of Black consumers; Works cooperatively and collaboratively with others to advance the health care needs of Black consumers; Provides white papers and testimony to legislators delineating the issues/concerns of Black consumers; Educates consumers as to the relationship between current and future laws and policies and the health care needs of Black consumers.
6.	Nursing Management Demonstrates management skills; Demonstrates leadership by promoting administrative and managerial best practices and standards in patient-centered health care delivery settings; Provides and promotes optimal supervisory climate, career mobility and educational opportunities (tuition remission, flexible work schedules) and mentoring for nurses at all levels.