Northeast Region Wound Ostomy Continence Nurses Society

New York, New Jersey, Pennsylvania

NORTHEAST REGION OF WOCN: WOCN NURSE OF DISTINCTION AWARD

NOMINATION FORM PART I

Both forms MUST be COMPLETED by nominee and nominator before sending in.

Those not completed are ineligible for consideration by the Nominating Committee.

Nominating nurse to complete form and send with Form II to:

Linda Rahuba, 67 East Amanda Street, Pittsburgh, PA 15210-1727 or llrrpen1@aol.com

(after llrrpen is the number 1 not an “L”) no later than September 23, 2006

Nominee Information:

I. First Name Initial Last Name

Address Office Address or Street Address City, State. Zip Telephone

Nominees Current Position:

Please list Title, Employer, and a brief description of current position and responsibilites

II. Nominating Entity’s Statement:

Please make a statement in the field below describing why your nominee is an outstanding WOCN and why he/she has been nominated. Please include in your description information about the following criteria:

	Nature, variety, and complexity of nominee’s achievements (how excellent and high professional standards are demonstrated).
	Outstanding accomplishments.
	How nominee has served as a role model for colleagues.
	What personal qualities enhance the nominee’s practice as a WOC nurse.
	What services nominee provides to the community.
	Other factors pertinent in your decision to nominate this individual.

Type statement and description here

III. Nomination: I hereby nominate for the Northeast Region of WOCN’s “WOCN Nurse of Distinction” Award.

Nominator Signature Title Date

NORTHEAST REGION OF WOCN: WOCN NURSE OF DISTINCTION AWARD

NOMINATION FORM PART II

Nominee to complete form and send with Form I to:

Linda Rahuba, 67 East Amanda Street, Pittsburgh, PA 15210-1727 or llrrpen1@aol.com

(after llrrpen is the number 1 not an “L”) no later than September 23, 2006

Nominee: Initial Last

Home address: Street Address City, State. Zip Code Telephone:

Current Job Title:

Place of Employment:

Certification: Expiration Date

List Memberships in Professional Associations (If necessary send email with additional):

Academic Background: List most recent first and include post-secondary studies related to your profession.

Describe your scope of practice as a WOCN nurse. Areas to consider include clinical practice, administration, community service, leadership, publication, research, and activities for NER/WOCN.

Nomination: I accept the nomination for WOCN Nurse of Distinction Award.

Signature Date