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Please enable JavaScript in your browser to complete this form.
This is a self-nomination?
Yes
No
Name of Nominee:
Name of Nominator(s)/ Endorser(s):
Role and Relationship of Nominator(s) with Nominee:
Nominee’s Current Place of Employment:
Is the Nominee currently registered in Ontario as an RN or RPN or RN(EC)?
RN
RPN
RN(EC)
How long has the Nominee been working at the current place of nursing employment?
If less than one year, please list previous employer(s):
Is the Nominee a member of CARE Centre for Internationally Educated Nurses?
Yes
No
Joan Lesmond Award Nomination Form Rating Scale
Categories are based on College of Nurses of Ontario Professional Standards (to be completed by the Nominee, Nominator or Endorser)
Name of Nominee:
Name of Nominator(s)/ Endorser(s):
Category of nomination:
RN
RPN
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
CATEGORY ONE: Respect, Teamwork
Showing Respect in all of his/her dealings with his/her colleagues and clients
0
1
2
3
4
5
Maintains and continually improves her/his competence by participating in the College of Nurses of Ontario’s Quality Assurance (QA) Program.
Encouraging Teamwork that clearly values collaboration & input towards organizational success.
0
1
2
3
4
5
Understands, upholds and promotes the values and beliefs described in CNO’s Ethics practice standard.
CATEGORY TWO: Accountability, Professionalism
Emphasizing Accountability at both the client and team level.
0
1
2
3
4
5
Continually improves the application of professional knowledge.
Focusing on Professionalism in all he/she does.
0
1
2
3
4
5
Demonstrates her/his leadership by providing, facilitating and promoting the best possible care/service to the public.
CATEGORY THREE: Compassion, Diversity
Showing understanding and Compassion to all those he/she works with and those he/she serves.
0
1
2
3
4
5
Professional relationships Establishes and maintains respectful, collaborative, therapeutic and professional relationships.
Championing Diversity of his/her clients by contributing to the building of a culturally competent care provision and working environment.
0
1
2
3
4
5
Professional relationships Establishes and maintains respectful, collaborative, therapeutic and professional relationships.
Total Scores
8. 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.
ENDORSER:1
Name:
Date:
Organization:
Position:
Signature:
Phone:
ENDORSER:2
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:
PERSONAL ESSAY BY NOMINEE
Please include a personal essay about your experiences. This essay should demonstrate your personal commitment to nursing. Your own “story” will also be assessed as part of this nomination. The reviewers will be looking at your story for indicators of courage, resilience, passion. The essay should be copied into the page(s) below. 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.
Submit
