### LILLIAN D. WALD PUBLIC HEALTH NURSING AWARD

## NURSING SECTION AWARDS NOMINATION FORM

Description of the Award: of the Award: The Lillian D. Wald Public Health Nursing Award honors a public health nurse who has provided exemplary public health nursing leadership in the state of Georgia. The purpose of this award recognizes demonstrated initiative and resourcefulness in developing efforts to improve the health of the public through political, legislative, professional or interdisciplinary collaboration. This award is made by GPHA in collaboration with the Office of Nursing, Division of Public Health. Nominee Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_County: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_GA Zip:\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Agency:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Position:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Nominated by:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_City:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_GA Zip:\_\_\_\_\_\_\_\_\_\_\_\_ Telephone:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FAX: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

FAX:

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Name of GPHA PHN Section Sponsor:

Nomination Requirements: Requirements: The nominations should describe how the nominee has provided excellence in population health practice.

### Criteria for Selection:

Nominees must have demonstrated initiative and resourcefulness in developing efforts to improve the health of the public through at least one: Political Legislative Professional Interdisciplinary collaboration.

Achievements should represent a leadership role in one or more of the following arenas: Promoting health activities for client groups. Influencing health policy and health laws. Collaborating with physicians, legislators and public officials. Strengthening public health nursing practice.

Nominees may include staff public health nurses as well as individuals with supervisory, management and/or leadership job responsibilities. 1. INNOVATION: How did the nominee do something that was new or unique? 2. IMPACT: What did the nominee do to improve the quality of Public Health services? 3. TIMELINESS: How did the nominee's activities address a current Public Health problem? 4. VISIBILITY: How did the nominee increase the community's awareness of Public Health? 5. INITIATIVE: How did the nominee demonstrate initiative or persistence in his/her activities?

The nomination form should not be longer than 4 pages including the Nomination Form. All 5 Criteria for Selection should be addressed. Attachments will not be accepted. ******************************************

### NOMINATION DEADLINE: JANUARY 10, 2013

Send to: Margaret R. Bean District Program Manager Northwest Georgia Health District Phone: 706-295-6647 1309 Redmond Road, NW Fax: 706-802-5681 Rome, Georgia 30165-9655