2017 Award Nomination Form

I am interested in submitting for consideration by the MNA Awards Committee the name of the individual indicated below for one of the following awards.

NOTE: The entire form must be completed and submitted in one session; you cannot save a partially completed form.

Receipt of online submissions will be confirmed by email to the nominator.  If you do not receive confirmation, please contact Liz Chmielinski at 781.830.5719 or echmielinski@mnarn.org.

  Elaine Cooney Labor Relations Award   Kathryn McGinn Cutler Advocate for Health and Safety Award
           
  MNA Human Needs Service Award   MNA Research Award
           
  MNA Image of the Professional Nurse Award   MNA Judith Shindul Rothschild Award
           
  MNA Advocate for Nursing Award   MNA Bargaining Unit Rookie of the Year Award
           
  MNA Nursing Education Award
  • Professional Nursing Education
  • Continuing Education/Staff Development
  MNA Excellence in Nursing Practice Award
   
Retired MNA Member Award
           
  Doris Gagne Addictions Nursing Award   MNA Mentor Award
           

Nominees for all but the Advocate for Nursing Award, the Kathryn McGinn Cutler Advocate for Health and Safety Award, and the Human Needs Service Award must be MNA members.

Please do not abbreviate:

Name of Nominee  
MNA Membership #  
Address  
City  
State  
Zip  
Home Phone  
Business Phone  
Educational Preparation (school, degree, year):  
Present Employment:  
Work History:  
Present Offices/Association Activities: (Congresses, Task Forces, Committees) If applicable
Regional Councils:  
MNA:  
     
Past Offices/Association Activities:  (past five years only)
Regional Councils:  
MNA:  
     
Other Professional/Community Activities:
   
     
     

Statement of the Nominator:  Please provide information to support your nomination, addressing each criterion listed under the award for which this individual has been nominated. 

The following statement applies only to nominees who are members of MNA or non-RN full Labor Relations Program members. 

I verify that this nominee has not violated a lawful MNA work action/strike and has not engaged in any anti-union activity.

Signature of Nominator (Please enter your name here to electronically sign this application.)  
Address  
City  
State  
Zip  
Home Phone  
Work Phone  
MNA Membership Number  
 Nominator's Email Adress  

Please note:  The nominator must have obtained the nominee’s permission to submit the nomination.

THE NOMINATOR IS RESPONSIBLE FOR SUBMITTING THIS COMPLETED MNA AWARD RECOMMENDATION FORM WITH ALL OF THE FOLLOWING: (Please verify that each item listed below has been included with this form.)

  A statement (included as a field in this form called Statement of the Nominator) indicating why the individual you have recommended qualifies for this award. (Download award criteria). Address each criterion separately.
     
  Resume or work history of nominee. Resume may be submitted as a word document or pdf in a separate email to echmielinski@mnarn.org
     
  One letter of support from an individual (other than the nominator) or structural unit giving examples of how the nominee meets the award criteria. (Please limit to 150 words.)
Name of third party individual
Go to the letter of support form in a new browser window here.
     
 

Is the bargaining unit committee aware of this nomination? Yes  No 

Name of committee member aware of nomination

     

Nominations must be accompanied by the required information list above. You will be notified by e-mail if your submission is incomplete. Nominations received at MNA after the deadline will not be accepted.