Caregiver Category Non Sector Specific
NOMINATION FORM 2017
HealthcareHumanityAwards 2017
CAREGIVER CATEGORY – NON SECTOR SPECIFIC
The Caregiver Category is open to nominations from all Healthcare/Social and Community CareOrganisations. This nomination is non sector specific.If you have met a Caregiver of one of your patients/beneficiaries or know of a Caregiver who inspires you, please share his/her story with us.
Part A: PARTICULARS OF CAREGIVERFull Name (as per NRIC/Passport)(Pls underline surname) / Salutation (Dr/Prof/Mr/Ms/Mdm)
Telephone (HP)
Name of Patient With Whom Caregiver Works / Relationship of Caregiver to Patient
Patient Seen By (Specify Specialisation) / Organisation Caring for Patient
Part B: PARTICULARS OF NOMINATOR
Full Name of Nominator / Name of Organisation
Designation / Relationship to Caregiver,e.g.,MSW assigned to the patient
Telephone (HP) (Office)
Note: The judging panel may conduct interviews as necessary to assess the nomination.
Part C: DETAILS
Q1.Please state the relationship between the caregiver and the patient. Is thecaregiver the sole caregiving provider to the patient?
(Sample Answer: The caregiver is the husband of the patient.)
A1.
Q2.How long has the caregiver been caring for the patient?
(Sample Answer: Louis was devoted to caring for his wife since she was diagnosed with stomach cancer in 2013.)
A2.
Q3. Describe the daily duties and responsibilities of the caregiver.
(Sample Answer: Louis insists on caring for his wife himself as he knowsthat she is not comfortable with strangers touching her. He encourages her constantly with loving words and gives her moral support. Besides attending to her daily needs such as bathing, cooking, feeding and changing her diapers, he also reads to her frequently and thinks up new ideas to keep her occupied and distracted from her constant pain.)
A3.
Q4. Describe some of the challenges faced by the caregiver.
(Sample Answer: Louis is unable to give his wife a proper bath as he lacks the strength to carry her and is wheelchair-bound himself. He can only give her daily sponge baths.They also face financial difficulties as the couple is not working.)
A4.
Q5. Please summarise the caregiver’s exemplary care and describe the sacrifices of the caregiver in caring for the patient full time.
(Sample Answer: The level of care and devotion Louis showers on his wife is admirable and has always been a source of inspiration to those around him. Despite the constant challenges, Louis remains optimistic and never lets his disabilities affect his life.When his wife’s illness gets too tough for him to deal with, Louisfindsstrength in his faith.He is also the pillar of support for his wife, constantly encouraging her and boosting her spirits, never letting her wallow in despair.
Louis shows great resilience in spite of all the challenges and is an inspiration to other caregivers in thepalliative caregiver support group. He listens to theirstruggles and gives words of encouragement when theyare feeling down. Louis is selfless andshows care to everyone he knows despite his own personal problems.
Ultimately, Louis’positive attitude and his ability tocount his blessings are the very things that inspire those around him.)
A5.
Congratulations on completing this form.
Please save the file as a Microsoft Word document according to the following file name format and send it to your institutional coordinators for collation.
[CATEGORY CODES]_[ABBREVIATED ORGANISATION NAME]_[FULL NAME OF NOMINEE]
CATEGORY CODES:
OPEN: OP
ILTC: IL
CAREGIVER:CA
VOLUNTEER: VO
ABBREVIATED ORGANISATION NAME:
E.g., SGH, BVH, SAMH, AMKTHK
Example:
The caregiver’s name is LouisTan and the nomination is submitted by XYZ Hospital. Therefore the file name should read:
CA_XYZH_LouisTan
Closing Date: 25 Nov 2016
Thank you for your nomination!
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