Top 5 LPN Award Nomination Form

Top 5 LPN Award Nomination Form

Please fill out the following questions to nominate a nurse for the award. Your responses will help us recognize outstanding nursing professionals.
Nominator Full Name

First NameMiddle NameLast Name
Nominator Email Address
example@example.com
Nominee's Full Name

First NameMiddle NameLast Name
Facility Name
Please provide the name of the healthcare facility where the nominee works.
Nominee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nominee's Personal Email
example@example.com **Please note that some healthcare facilities have security protocols that prevent work emails from receiving messages from external sources.
General Directions

Please use the prompts below to describe how this nurse exemplifies excellence in each category.
The strongest nominations include specific examples, stories, actions, and outcomes that demonstrate the nominee's impact. Whenever possible, describe:
- The situation or opportunity
- The actions taken by the nurse
- The resulting impact on patients, families, colleagues, the organzation, or the community
Focus on evidence of excellence rather than general praise. Specific examples help reviewers understand how the nominee consistently goes above and beyond in their practice and service.

To ensure a fair and unbiased review process, please do not include the nominee's name, employer, unit, or other identifying information in your submission.
Personal Dedication and Passion (250 words max)

Describe the qualities, values, and behaviors that make this nurse a model of excellence in nursing.0/250
Consider sharing examples that demonstrate:
- Compassion, empathy, and patient advocacy
- Commitment to patient and family centered care
- Professionalism, integrity, and accountability
- Resilience during challenging situations
- Going above and beyond expectations to support patients, families, or colleagues
Provide one of more specific examples that illustrate this nurse's dedication and explain the impact of their actions.
Innovation & Continuous Improvement (250 words max)

Describe how this nurse has contributed to improving patient care, processes, outcomes, safety, efficiency, or the nursing practice environment.0/250
Consider sharing examples of:
- Problem-solving and creative thinking
- Quality improvement initiatives
- Evidence-based practice changes
- New ideas, workflows, or approaches to care
- Improvements that enhanced patient, staff, or organizational outcomes
Describe the challenge or opportunity the nurse's actions, and the resulting impact or outcomes whenever possible.
Community Engagement (250 words max)

Describe how this nurse contributes to health and well-being in the community outside of their formal clinical responsibilities.0/250
Consider sharing examples of:
- Volunteerism and community service
- Health education and outreach
- Advocacy for vulnerable or underserved populations
- Participation in charitable, civic, or health-related organizations
- Programs or initiatives that promote community wellness
Explain how this nurse's involvement has made a positive difference in the lives of individuals or the broader community.
Leadership and Mentoring (250 words max)

Describe how this nurse has demonstrated leadership and contributed to the growth and success of others.0/250
Consider sharing examples of:
- Mentoring, coaching, or precepting
- Supporting new nurses, students, or colleagues
- Leading projects, teams, or practice improvements
- Promoting teamwork, collaboration, and professional development
- Influencing positive change within the profession or workplace
Provide specific examples of how this nurse's leadership has helped others grow, improve outcomes, build confidence, or achieve success.

Tips for a Strong Nomination

The strongest nominations:
- Include specific examples rather than general praise
- Describe actions and outcomes
- Highlight sustained contributions and impact over time
- Demonstrate how the nominee exceeds expectations
- Provide evidence of influence on patients, families, colleagues, or the community
Should be Empty:

Top 5 LPN Award Nomination Form

General Directions