Joan Lesmond IEN of the Year- Nomination Form

This is a self-nomination? *

Name of Nominee: *

Name of Nominator(s)/ Endorser(s):

Role and Relationship of Nominator(s) with Nominee:

Nominee’s Current Place of Employment: *

Under which professional registration category is the Nominee currently applying for this award? *

RN
RPN
RN(EC)

How long has the Nominee been working at the current place of nursing employment under this professional registration category?

If less than one year, please list previous employer(s):

Is the Nominee a member of CARE Centre for Internationally Educated Nurses? *

Joan Lesmond Award Nomination Form Rating Scale

Categories are based on CARE values- Respectful, Collaborative, Compassionate, Accountable, Professional, Inclusive. To be completed by the Nominee, Nominator or Endorser.

A) Please rate criteria on a scale from 0 to 5 and provide comments.

0-absent, 1-fair, 2-good, 3-very good, 4-excellent, 5-exceptional (30 points)

CATEGORY ONE: Respect, Collaborative

Showing Respect in all of his/her dealings with his/her colleagues and clients *

Encourages and values collaboration & input towards organizational success. *

CATEGORY TWO: Compassionate, Accountability

Showing understanding and Compassion to all those he/she works with and those he/she serves. *

Emphasizing Accountability at both the client and team level. *

CATEGORY THREE: Professional, Inclusive

Focusing on professionalism in all he/she does. *

Championing inclusivity of his/her clients by contributing to the building of a culturally competent care provision and working environment. *

Total Scores *

Comments:
Please provide comments (or attach a letter of reference) containing examples of how the IEN being nominated demonstrates the above criteria. Including supporting information or feedback from Peers, Patients/Clients or Families would be helpful. (40 points)

File Upload

Click or drag files to this area to upload. You can upload up to 4 files.

If self-nominating, two (2) endorsements are required in the form of signatures from any of the following:

• Manager and/or Administrator
• Team Leader, Clinical Educator or Preceptor
• Peers (nurses, health care discipline team members - physicians and allied health professionals)
• Patients and Families
• CARE Centre Case Manager

ENDORSER:1

Endorsement(s) from: (name, role, organization) By putting your name to this document you are acknowledging that you have read the examples (1-7) above and agree the nominee has demonstrated each in an exemplary manner.

Name:

Date:

Organization:

Position:

Signature:

Phone:

ENDORSER:2

Name:

Date:

Organization:

Position:

Signature:

Phone:

Are you willing to participate in an evaluation about this Award Process in the future?
Yes
No

Phone *

Email *

PERSONAL ESSAY BY NOMINEE (30 points) *
Please include a personal essay about your experiences. This essay should demonstrate the nominee’s personal commitment to nursing and courage, resilience, and passion as an IEN, displaying these with anecdotal evidence from the IEN’s nursing practice that demonstrates the following values: Respectful, Collaborative, Compassionate, Accountable, Professional, Inclusive. Your “story” will also be assessed as part of this nomination. The essay should be copied into the online nomination form above. Essays over 500 words will not be read.
THE ESSAY MUST BE INCLUDED WITH THE FORM FOR A COMPLETE SUBMISSION. Please feel free to discuss with your CARE Centre Case Manager for assistance or ask your colleagues/manager/supervisor to assist you with this process.

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