School Nurse of the Year Nomination Form

School Nurse of the Year 2024 - 2025

This award recognizes an outstanding school nurse for his/ her contribution to the school and community. To be eligible for this award, your school nurse must meet the following criteria:

Hold a License in the State of New Hampshire as a Registered Nurse
Currently practicing school nurse with minimum 3 years school nurse experience
Current and 2 continuous years of membership in NHSNA

This should be an open nomination process to allow for collaboration with the Nominee and facilitate collection of pertinent supporting documentation.

Items to gather to complete the nomination:

1. Nominee's Resume/ Curriculum Vitae
2. Nominee's personal contact information
3. Demographic & general information regarding school/ district/ job description
4. Confirmation that your Nominee is a member of NHSNA for two consectutive years You may email us at nhschoolnurses@gmail.com for this information.
5. Letters of Recommendation (up to 2)
6. Narratives, exemplars, artifacts supporting the Nominee's accomplishments in the following domains:

provision of care
program management
health education
professional development
community involvement
nursing research

Nominator's Information

Nominator's Name*

First NameLast Name

Nominator's Phone Number:*

Area CodePhone Number

Nominator's E-mail Address:*

example@example.com

School Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Nurse's Information

Nurse's Name with Credentials:*

First NameLast Name

Present Position:*

Number of years in this position:*

Grade levels served:*

Does this nurse supervise other staff?*

YesNo

Is this nurse an active member of the New Hampshire School Nurses' Association for two consecutive years? (NHSNA) If you do not know the answer, please email nhschoolnurses@gmail.com*

YESNO

Please explain how this candidate demonstrates a leadership role in the following six domains:

Each of the domains are scored on a 0 -3 point scale to generate a total score using the following rubric:

0. No supporting narrative / examples given

1. Supporting narrative / examples given but do not make a clear connection to the domain

2. Supporting narrative / examples given and they provide a clear, relevant connection to the domain

3. Supportive narrative / examples are present, and represent a depth of experience and expertise within the domain

Domain 1. PROVIDER OF CARE: Expertise in school nursing practice:
Examples may reflect clinical knowledge and skills

nursing process
provider of student confidentiality and respect
provider of student advocacy
communication skills- written, verbal and non-verbal

PROVIDER OF CARE:*

Domain 2. PROGRAM MANAGEMENT:
Examples may include:

development of school and/or community projects
planning and assessment of school services
development and implementation of district, national or state policies
collaborator in student care
involvement in the development and implementation of Individualized Health Plans (IHPs), Individualized Education Plans (IEPs), and 504 plans

PROGRAM MANAGEMENT: *

Domain 3. HEALTH EDUCATION:
Examples:

Provider of continuing education to school staff
Provider of education to students
Participation on the wellness committee
Participation in curriculum development
Health resource facilitator

HEALTH EDUCATION:*

Domain 4. PROFESSIONAL DEVELOPMENT:
Examples may reflect:

Participation in continuing education opportunities
Membership in or service to professional organizations such as National Association of School Nurses (NASN), American Nurses Association (ANA) (NHNA), New Hampshire School Nurses’ Association (NHSNA)
Participation as a member to local, state or national non-profit programs that support youth
The nominee has been certified by the National School Nurse Certification Board

PROFESSIONAL DEVELOPMENT: *

Domain 5. COMMUNITY INVOLVEMENT:
Examples may reflect:

development of school and/or community projects
involvement in local, state or national legislative efforts
membership in PTSA
participates or leads an after school club

COMMUNITY INVOLVEMENT:*

Domain 6. RESEARCH:

The primary goal of a school nurse is to be the student's advocate and provide optimal care on the basis of evidence obtained through research.

Examples may reflect:

contributions to school nurse literature or professional publications
participation in or utilization of nursing research in daily practice

RESEARCH:*

Upload nurse's curriculum vitae or resume*

Browse Files

Upload up to 2 letters of recommendation

Browse Files

Letters may be from a supervisor, colleague, parent, students or other stakeholder.

Upload anything else you would like us to know.

Upload a File

Date of Submission*

Date