SCHCHA H.O.M.E. Awards Nomination
Please fill out this form to nominate for an award.
THANK YOU for nominating a HERO from your agency! SCHCHA's Annual HOME Awards Ceremony is a special event and nominating someone for these awards is an opportunity to celebrate all the great things they do each and every day. GUIDELINES: - Be sure to fully answer each question (answers are part of the scoring criteria). - Do not use the name of the nominee or any identifying information (such as agency name) on your narrative or in your answers. - The only place the nominee's name and agency should appear is in the nominee first/last name fields at the top of this form. - The Association's PR Committee will receive the narrative portion of the nominations only so that the awards selection process will remain anonymous. - Simply choose the nomination category you are submitting from the drop down menu below and complete the section. - You may submit more than one entry. Contact sue@ahhcnc.org with any questions.
Select an award category for your nominee below, then click next until you find the appropriate application for that category. Please fill out the application in its entirety. The categories this year are: Professional of the Year, In-Home Aide of the Year, Physician of the Year, Family Caregiver of the Year, and NEW - SCHCHA Hospice Veteran Partnership Leadership Award. Be sure to fill out your contact information on the last page and then hit submit.
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Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Professional of the Year
The nominee may be, but is not limited to: a registered nurse, licensed practical nurse, therapist, therapy assistant, nutritionist, pharmacist, clergy/chaplain, or social worker who has worked in home care and/or hospice for a minimum of three years. This award is intended to recognize a clinical professional in a direct care or mid-level management role.
2. Nominee Information
Nominee's Name
First Name
Last Name
Nominee's Title and Credentials
Nominee's Agency Name
Nominee's Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Number of Years Worked in Home Care and/or Hospice
To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
Check that you have answered the following criteria for scoring and provide an example.
Describe the clinical care provided by this individual and/or how he/she serves as an advocate for patients. (25 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe how this individual supports an interdisciplinary team approach. (25 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe how this individual works to enhance the care that the agency as a whole provides. Provide examples of innovation, professional skills, and/or leadership qualities demonstrated by the nominee. (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe efforts undertaken by this individual to enhance their professional growth, as well as the agency's growth. Include formal education, as well as workshops and other continuing education. (15 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
This individual deserves this distinguished award over all other nominees because...Use 100 words or less. (15 pts.)
Example
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Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
In-Home Aide of the Year
This award is designed to recognize in-home aides in the home health and hospice industry. The nominee must have a minimum of one year experience working in home health and/or hospice.
2. Nominee Information
Nominee's Name
First Name
Last Name
Nominee's Title and Credentials
Nominee's Agency Name
Nominee's Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years Worked in Home Care and/or Hospice
To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
Check that you have answered the following criteria for scoring and provide an example.
Describe the care provided by this individual and how he/she serves as an advocate for patients. (30 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe how this individual supports other members of the interdisciplinary team. (25 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe this individual's work habit and how he/she demonstrates excellence. (15 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe efforts undertaken by this individual to enhance their professional growth. (10 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
This individual deserves this distinguished award over all other nominees because...Use 100 words or less. (15 pts.)
Example
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Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Physician of the Year
This award is presented annually to a physician who has demonstrated a philosophical commitment to assisting home health and/or hospice patients who wish to remain at home.
2. Nominee Information
Nominee's Name
First Name
Last Name
Nominee's Title and Credentials
Nominee's Agency Name
Nominee's Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years Worked in Home Care and/or Hospice
To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
Check that you have answered the following criteria for scoring and provide an example.
Care-planning Process – actively participates in the care planning process, Understands Medicare/Medicaid coverage guidelines; timely paperwork completion/signature in accordance with regulatory requirements; Communicates problems with the plan of care instead of deleting care on orders (30 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Care management and collaborative team approach – demonstrates excellence in care management to enhance patient care and quality of life. Courteous, respectful, listens and is available to staff during and after hours regarding patient care. (30 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Outstanding consultative services – available for in-services, willing to share knowledge, discuss information on disease management, protocols, equipment, etc. Available to review policies, procedures on a consultative basis. (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Other attributes – serves above and beyond the call of duty, patient advocate, makes home visits, participates in case conference (20 pts.)
Example
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Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Family Caregiver of the Year
This award is presented to a non-paid family caregiver who goes above and beyond the call of duty to promote patient/client well-being and enhanced quality of life including but not limited to factors such as comfort, safety and independence.
2. Nominee Information
Nominee's Name
First Name
Last Name
Nominee's Title and Credentials
Nominee's Agency Name
Nominee's Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years Caregiving in Home Care and/or Hospice
To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
Check that you have answered the following criteria for scoring and provide an example.
Describe how the caregiver promotes the patient/client’s well-being, quality of life, and maximum independence. (30 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe the caregiver’s ability to learn care instructions and to intervene appropriately. (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe the adjustments made in caregiver’s personal life to provide care. (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Other attributes (attitude, flexibility, dependability, willing to advocate) (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
This caregiver deserves this distinguished award over all other nominees because . . . Use 100 words or less. (10 pts.)
Example
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Next
Save
Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
SCHCHA Hospice-Veteran Partnership Leadership Award
This award is designed to recognize a hospice employee who is a leader within their organization and their communities in efforts to better serve Veterans and their families. The nominee must have a minimum of one (1) year experience in a hospice setting. The nominating organization must be a member of SCHCHA and must be a participating organization in the NHPCO We Honor Veterans program.
2. Nominee Information
Nominee's Name
First Name
Last Name
Nominee's Title and Credentials
Nominee's Agency Name
Nominee's Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years Caregiving in Home Care and/or Hospice
To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
Check that you have answered the following criteria for scoring and provide an example.
Recount examples of this individual’s actions that demonstrate their commitment to Veterans and their care. (350 words or less). (40 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
When others comment on this individual and their impact on Veterans, what are the most common descriptors used? (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
What do Veteran patients/clients, their families, and the hospice staff most value about this individual’s contributions to your agency (100 words or less) (20 pts.)
Example
Check that you have answered the following criteria for scoring and provide an example.
Describe the value of this individual’s contributions and impact to your organization’s ability to provide care to Veterans and their families but also their impact in acknowledging and showing appreciation to Veterans. (100 words or less). (20 pts.)
Example
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3. Your Information
Your Name
*
First Name
Last Name
Your E-mail Address
*
Your Phone Number
*
-
Area Code
Phone Number
Your Agency Name
*
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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