Hall of Fame Nominations - Missouri Nurses Association

NOMINATOR INFORMATION:

Nominator First Name: *

Nominator Last Name: *

Nominator Type: *

Individual MONA Member

MONA Board of Directors

MONA Committee

MONA Group

Nominator Street Address: *

Nominator City: *

Nominator State: *

Nominator Zip: *

Nominator Preferred Phone: *

Nominator Email: *

Individual Member Nomination Supported By: (2 signatures required for nominations submitted by individual MONA Members)

Supporting MONA Member Name 1:

Supporting MONA Member Name 2:

Two short letters of support for the nominee describing how the criteria is met; these should not exceed 100 words:

Letter of Support 1: *

.pdf, .doc or .docx formats are accepted.

Letter of Support 2: *

.pdf, .doc or .docx formats are accepted.

By Submitting This Form, You Agree: *

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS NOMINATION PACKET IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

NOMINEE ELIGIBILITY REQUIREMENTS:

The nominee is a Registered Professional Nurse: *

Yes

The nominee is a Registered Nurse licensed in the state of Missouri: *

Yes

The nominee lived or worked in the state of Missouri during some period of his/her career: *

Yes

The nominee is or has been a member of the Missouri Nurses Association: *

Yes

The achievements of the nominee have enduring value to nursing beyond the nominee’s lifetime: *

Yes

The nominee made significant contributions to the nursing profession in clinical practice, education, administration, organizational work involving health care or innovation in health care delivery systems, or to the Missouri Nurses Association enterprise *

Yes

The nominee demonstrated leadership in two or more of the following areas: *

a. Advanced the practice of nursing as a profession;
b. Improved the quality of health care;
c. Adhered to professional nursing standards;
d. Supported professional nursing education in the state of Missouri;
e. Influenced health care policy;
f. Contributed to the enhancement and progress of the nursing profession on a state, national and/or international level

Yes

NOMINEE INFORMATION:

Nominee First Name: *

Nominee Last Name: *

Nominee Street Address: *

Nominee City: *

Nominee State: *

Nominee Zip: *

Nominee Preferred Phone: *

Nominee Email: *

Nominee Present Employer:

Nominee is/was a member of the Missouri Nurses Association: *

Yes

If Yes, for how many years? *

Education: (begin with the highest degree earned)

NARRATIVE STATEMENT:

Once a nominee is selected and has accepted their induction to the hall of fame, a MONA committee member will conduct an interview with the nominee. The committee member will then write a narrative based on the interview, and will then submit the narrative to the nominee for final approval.

The following elements will be considered when preparing the narrative statement:

Contributions in health-related areas with global impact
Significant impact throughout her/his career that influenced healthcare in Missouri
Change agent in the delivery of care and influence on nursing practice
Held leadership position(s) in healthcare and/or education that influenced the nursing profession
Contributions as an elected officer in nursing professional organizations, service, and influence on nursing practice
Research & Development involving programs that improve patient care
Innovation affecting healthcare and/or practice with a state or global impact
Held or currently holding statewide office
Years practiced as a Registered Nurse
Years actively engaged in healthcare
Published articles, chapters and/or books that influenced education, administration or practice
Speaker at state or national conferences
Consultant on state or national issues impacting the nursing profession
Received prior recognition for nursing excellence

OPTIONAL SUPPORTING DOCUMENTS:

The following is additional information about the nominee that may assist the awards committee during the selection process:

CV/Biographical Data:

Detailing the nominee’s educational background, work experience, publications, community contributions, honors and awards.

A Photo of the Nominee:

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