CONGRATULATIONS, NOMINEE!
DIRECTIONS ON HOW TO BECOME AN OFFICIAL NOMINEE:
Previous winners may be nominated if it has bee...
BIOGRAPHICAL DATA FORM
P L E A S E T Y P E o r P R I N T L E G I B L Y
Name Home Telephone #
Home Address Email
City State...
Please CHECK ONLY ONE to indicate your PRIMARY area of nursing practice.
(Please note that your job description must suppo...
P L E A S E T Y P E o r P R I N T L E G I B L Y
What have you done in the past year to contribute to the nursing professio...
Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009
P L E A S E T Y P E o r P R I N T L E G I B L Y
Re...
Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009
P L E A S E T Y P E o r P R I N T L E G I B L Y
Li...
Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009
P L E A S E T Y P E o r P R I N T L E G I B L Y
Li...
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BIOGRAPHICAL DATA FORM

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Transcript of "BIOGRAPHICAL DATA FORM"

  1. 1. CONGRATULATIONS, NOMINEE! DIRECTIONS ON HOW TO BECOME AN OFFICIAL NOMINEE: Previous winners may be nominated if it has been at least five years and they qualify for a different category! 1) Fill out the form completely. Do not leave blanks (mark N/A where applicable). 2) On page 3 choose the one category that reflects your primary area of nursing practice. 3) Typewriting is preferred, legible printing is acceptable. Illegible handwriting WILL disqualify nominee! This form is also available on the website www.marchofdimes.com/nevada). 4) Include all work-related and personal achievements – nothing is “too big” or “too small!” 5) Examples for the question on page 4 “What have you done n the past year to contribute to the nursing profession?” for you to consider are:  How did you contribute to a positive patient outcome?  Patient/customer satisfaction.  Improving nursing care and outcome.  Positively influencing your peers.  Policy and Program development. 6) Please read all instructions carefully under each heading and formulate your answer from your perspective. 7) Please limit the time frame for information from the past year (July 1, 2008 to June 30, 2009.) Please DO NOT submit a CV (Curriculum Vitae) in place of the Biographical Form. Doing so WILL disqualify you from the judging process. 8) Please provide a letter of recommendation. Maximum of three letters will be accepted. You may use the form provided or your own format. 9) Please INCLUDE COPIES OF ALL CERTIFICATION including ACLS and Specialty Certificates. If you do not provide the copies you will not receive the points. Failure to do so will result in a lower score. 10) Please contact your Facility’s Nurse of the Year Committee member if you have any questions or need further assistance. 11) Please return the completed form (TWO COPIES) by mail, or hand-deliver to the March of Dimes office: 820 Rancho Lane, Suite 55, Las Vegas, NV 89106 on or before September 30, 2009. MARCH OF DIMES NURSE OF THE YEAR AWARDS 1 of 7
  2. 2. BIOGRAPHICAL DATA FORM P L E A S E T Y P E o r P R I N T L E G I B L Y Name Home Telephone # Home Address Email City State Zip Employer Name or Agency Name Work Telephone # Title How Long? Employer Address or Agency Address Email City State Zip Signature* Electronic Signatures are acceptable Date* * Signature/date are required to attest to the accuracy of the information provided, and to serve as permission to verify information. I have been a resident of Nevada for _________ years and __________ months. I have been a Nurse for __________ years and __________ months. I graduated in __________ of __________ These questions must be completed to be eligible for judging! List any and all positions / employers within the past 12 months: A. Employer Position B. Employer Position 2 of 7
  3. 3. Please CHECK ONLY ONE to indicate your PRIMARY area of nursing practice. (Please note that your job description must support the category chosen) Category Includes  ADVANCED PRACTICE Clinical Nurse Specialist, Certified Nurse Midwife, Nurse Practitioner and Nurse Psychotherapist.  CASE MANAGEMENT Nurses actively engaged in the professional practice of case management in any health care setting. One who performs clinical assessments and/or advocates for appropriate patient admissions to specialty units/programs.  CHARGE NURSE ~ GENERAL MEDICAL & SURGICAL Includes nurse’s in general medical and surgical areas of nursing who function in the charge nurse role.  CHARGE NURSE /SPECIALTY Includes nurses in any specialty unit area of nursing who function in the Charge Nurse role. Includes Adult ICU/CCU, IMC, cath lab and special procedures, PTCA Interventional Radiology, ER, Surgical, Labor & Delivery, NICU with intermediate care units and PICU.  CRITICAL CARE Includes adult ICU/CCU, IMC, cath lab and special procedures, PTCA Interventional Radiology, PICU, NICU with intermediate care units.  EDUCATION Includes University / Junior College, Hospital and Community (schools etc.)  EMERGENCY ER, flight, ambulance, pre-hospital, telephone triage and Peds ER.  GENERAL MEDICAL/SURGICAL Medical, surgical, orthopedics, neurological, renal respiratory, cardiovascular, nursing dependent upon specialty for either category.  HOSPICE NURSING, HOME HEALTH & PALLIATIVE CARE Nursing in inpatient/outpatient hospice settings and nursing in all home health care settings.  INFECTION CONTROL & OCCUPATIONAL HEALTH Nursing in IC/EH and Occupational Health Settings.  LONG TERM ACUTE CARE/LONG TERM/REHAB Nurses caring for patients in specialty Long Term Acute Care Hospitals, Skilled Nursing Facilities and Acute Rehabilitation Long Term Care Facilities.  MANAGED CARE Nursing in managed care/health maintenance organization settings.  NURSING ADMINISTRATION Includes Entrepreneurs, Researchers, Consultants, CNE’s, CNO’s, VP’s and Administrative Directors.  NURSING MANAGEMENT Includes those with supervisory roles in a clinical or non-clinical setting: full-time, shift/clinical coordinators and Department Directors/Department Managers.  ONCOLOGY NURSING Nursing in all oncology settings, adult and pediatric.  PEDIATRIC NURSING Nursery, general pediatric units, pediatric clinics.  PUBLIC HEALTH AMBULATORY CARE & BEHAVIORIAL HEALTH Public health, clinic, office and other ambulatory care settings and/or school, transplant coordinators, parish and prison nursing. Mental Health and Addictive Services.  QUALITY & RISK MANAGEMENT Performance Improvement, Quality Management, Risk Management, Informatics, Patient Advocate, Patient Safety, in the Community and/or Hospital.  SURGICAL SERVICES Perioperative, Preoperative, PACU, Day Surgery, OR and Endoscopy.  WOMEN'S HEALTH Antepartum, Intrapartum, Maternal/Baby Care, Postpartum and Gynecology. 3 of 7
  4. 4. P L E A S E T Y P E o r P R I N T L E G I B L Y What have you done in the past year to contribute to the nursing profession? (Judging = 40%) Examples:  How did you contribute to a positive patient outcome?  Patient/customer satisfaction.  Improving nursing care and outcome.  Positively influencing your peers.  Policy and Program development. 4 of 7
  5. 5. Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009 P L E A S E T Y P E o r P R I N T L E G I B L Y Recommendation Letter (max 3) PLEASE DO NOT SUBMIT ON COMPANY LETTERHEAD AND ONLY USE APPLICANT’S NAME ONE TIME! (can use this form or can be in form of letters) Name of Nominee Please describe your affiliation/work history with nominee: How do you see the nominee contributing to nursing? (Example: inovative, team work, advocacy nursing theory) What makes this person stand out in the profession of Nursing? I hereby certify that the above information is accurate to the best of my knowledge. Signature: Title: Print Name: 5 of 7
  6. 6. Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009 P L E A S E T Y P E o r P R I N T L E G I B L Y List current memberships/offices (i.e., President, secretary) / committees (i.e., Chair, member) / taskforces in professional healthcare-related organizations. Outline contributions and leadership activities (Judging = 15%). Organization / Address Office / Position Held (List responsibilities & contributions) List current professional certifications at national, regional, or local levels (ex. Certified obstetric nurse, certified case manager) that you hold. (Judging = 10%) YOU MUST ATTACH A COPY OF CARD OR CERTIFICATE FOR JUDGING CRITERIA. FAILURE TO DO SO WILL RESULT IN “ZERO” POINTS. Certifications/Organizations/Affiliations o CCRN (Critical Care) o NCC (OB / Neonatal) o CNOR (Operating Room) o CEN (Emergency) o Medical-Surgical Specialty o Orthopedic Nursing o ACLS o PALS o NRP o ENPC o TNCC o S.T.A.B.L.E. o Fetal Monitoring o CCM o CPUR o CRI o CPHQ o CIC o Other __________________________ o Other __________________________ o Other __________________________ 6 of 7
  7. 7. Please Limit Data to the Time Frame from: JULY 1, 2008 TO JUNE 30, 2009 P L E A S E T Y P E o r P R I N T L E G I B L Y List community or volunteer service activities (i.e. Church, PTA, March of Dimes, or other service organizations). Outline committee work, leadership activities, and other contributions. (Judging = 10%) Examples: member, officer, or board member in non-professional organization. Activity & Date Describe your Role o Church Volunteer o Parent Teacher Groups o March of Dimes o Other Non-profit organization o Club Sports volunteer o Youth Groups Volunteer o Volunteer Work o Other List professional achievements, such at presentations, publications, and awards at any level (national, regional, local). Include in-services presented newsletter articles, or recognition within your own agency. (Judging = 15%) List completion of degrees (ex. BSN, MSN), or courses of study (ex. College credit, special training). Activity & Date Describe your Role 7 of 7

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