MAR Nurse of the Year Nomination Form

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2022 Nurse of the Year Criteria and Nomination Form

Submission Deadline: August 1, 2023

Nominee Criteria:

Current active member of the Mid-Atlantic Region of the WOCN^® Society - (Member of the WOCN^® Society with MAR or one of its affiliates selected as their region)
Engaged in clinical practice of wound, ostomy, continence or foot care nursing
Certified by the WOCNCB^® in one of the following: wound, ostomy, continence and/or foot care
Endorsed by one or more peers for recognition status

All information potentially identifying the nominee will be redacted for an impartial blind vote by the MAR NOY/Scholarship committee.

NOTE: It is recommended to print the blank submission form to review prior to completing.

Once you have started the application it cannot be saved. If this page is closed without submission, all information entered will be deleted.

Fields with * are required. Complete all other fields as appropriate or enter "N/A" if not applicable.

Nominee Information

*Email Address:

*First Name:

*Last Name:

*Address:

*City:

*State:

*ZipCode (5 digits):

*Phone with area code and type:

Home Work Mobile

*Is the Nominee employed as a WOC Nurse?

Yes No

Employer:

Title or Role:

Name of Nursing School Attended:

WOCET_NEP:

Date of Certification:

Date of Re-Certification:

*WOCN^® Member ID #:

Enter "0" if unknown

*Mid-Atlantic Region member ?
Yes No Not Sure

Demonstrates excellence in the practice of WOC nursing by:
(300 words or less)

Exemplifies high professional standards as evidenced by: (300 words or less)

Provides service in the community: (300 words or less)

Promotes pride in the National WOCN^{^®} Society and the Mid-Atlantic Region of the WOCN^{^®} Society:
(300 words or less)

Demonstrates interest and positive attitude to meet the needs of patients, families, visitors, significant others, industry, co-workers, physicians and association:
(300 words or less)

List other achievements:
(300 words or less)

*Is the Nominee aware of this nomination ?