NOMINATION FORM 2017

HealthcareHumanityAwards 2017

ILTC (INTERMEDIATE LONG-TERM CARE) CATEGORY

FOR HOME CARE/DAY CARE/RESIDENTIAL SERVICES (ILTC/SOCIAL AND COMMUNITY CARE) SECTOR

i.e., Community Hospitals, Hospices, Nursing Homes, Day Rehab Centres, SACs, SCCs, Home Care Organisations and any other organisation that provides long-term care to a patient/client/beneficiary.

The ILTC Category is for all Healthcare Workers regardless of titles, e.g., Doctors, Nurses, Allied-Health Professionals, Support Staff with direct patient/client/beneficiary care.

Part A: PARTICULARS OF NOMINEE
Full Name (as per NRIC/Passport)(Pls underline surname) / Salutation
(Dr/Prof/Mr/Ms/Mrs/Mdm)
Telephone (HP) (Office)
Email
Designation/Title / Specialisation
Department / Name of Organisation
Part B: PARTICULARS OF NOMINATOR
Full Name of Nominator / Relationship to Nominee
Designation / Name of Organisation
Telephone (HP) (Office)
Email
Note: The judging panel may conduct interviews as necessary to assess the nomination.
Part C: PARTICULARS OF REFEREES
1ST Referee / 2nd Referee
Full Name of Referee / Full Name of Referee
Relationship to Nominee / Relationship to Nominee
Name of Organisation / Name of Organisation
Telephone / Telephone
Email / Email
Part D: DETAILS
Q1. Please providea brief summary of the nominee’s daily job description.
(Sample Answer: Jenny is an enrolled nurse. She looks after patients at the Dementia Ward in ABC Nursing Home. Her daily duties include serving meals to patients, assisting them with their baths, and interacting with them.)
A1.
Q2. Please tell us why you think thenominee deserves to be given this award. Does he or she exhibit one or all of the following values: Courage, Extraordinary, Dedication, Selflessness, Steadfastness in Ethics, Compassion and Humanity. Below are some questions to guide you as you share the story. Please feel free to elaborate beyond these questions.
  • How long has the nominee been working in your organisation?
  • Share with us the challenges faced by the nominee on a typical day at the ward/home/centre.
  • Share with us the condition of patientswho the nominee cares for on a daily basis.
  • Share with us the nominee’s disposition in the course of his/her daily work. Is the nominee cheerful, positive, patient, etc. towards patients?
  • Does this nominee regularly receive praise and thanks from patients’ family members? Has the organisation received any written compliments regarding this nominee? If yes, please scan and attach with this submission.

A2.
Q3. Please share a specific incident that comes to mind that distinguishes this nominee from others in your organisation.
A3.

Congratulations on completing this form.

Please save the file as a Microsoft Word document according to the following file name format and email it to your institutional coordinators for collation.

[CATEGORY CODES]_[ORGANISATION ABBREVIATED NAME]_[FULL NAME OF NOMINEE]

CATEGORY CODES:

OPEN: OP

ILTC: IL

CAREGIVER:CA

VOLUNTEER: VO

ORGANISATION ABBREVIATED NAME:

E.g., SGH, BVH, SAMH, AMKTHK

Example:

The nominee’sname is JennyTan and the nomination is submitted by ABC Nursing Home.Therefore the file name should read:

IL_ABCNH_JennyTan

Closing Date: 25Nov 2016

Thank you for your nomination!

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