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Canadian Hospice Palliative Care Association > About The Canadian Hospice Palliative Care Association > Awards > Award of Excellence > Award of Excellence 2023 Nomination Form

Award of Excellence 2023 Nomination Form

To ensure a smooth submission process, we recommend preparing your submission offline and then copying and pasting or typing it into the system.

Fields marked with an asterisk (*) are required

Award of Excellence 2023

Nomination Submission Form
The 2023 Deadline for Submission is September 1, 2023

Questions on submission of award nomination should be directed to [email protected]
Part One
Name of Nominee*
First Last
Is the nominee a current CHPCA Associate/Provincial Member?*
- Yes
- No
(Note: Nominee must have been a CHPCA Associate/Provincial Member for the past year and maintain current CHPCA Associate/Provincial Member status)
Address of Nominee*
Street Address Address Line 2 City Province Postal Code
Nominee's Home Phone No.*
Nominee's Daytime Phone No.*
Nominee's Email*
Hospice/Palliative Care Service or Program:*
Name of Nominator*
First Last
Is the nominator a CHPCA Associate/Provincial Member in good standing?*
- Yes
- No
(Note: Nominator must have been a CHPCA Associate/Provincial Member for the past year and maintain current CHPCA Associate/Provincial Member status)
Address of Nominator*
Street Address Address Line 2 City Province Postal Code
Nominator's Home Phone No*
Nominator's Daytime Phone No*
Nominator's Email
Did the nominator submit a nomination for this nominee during the last CHPCA Award of Excellence call for submissions?*
- No, the nominator did not submit a nomination for this nominee during the past award submission
- Yes, the nominator did submit a nomination for this nominee during the past award submission
The last call for submissions was for the 2019 Award of Excellence
The CHPCA Awards Committee is offering you the opportunity to allow a past nomination to stand for this year’s Award of Excellence. If you nominated an individual for the 2022 Award of Excellence and if you would like to proceed with nominating them again this year, you must fill out Part One of the Nominations form and you must contact the nominee and have them resign the Nominations Application Requirements Checklist and Signatures form. You must also ensure that their CHPCA associate / provincial membership is up-to-date. You do not need to resubmit Part Two of the application; however, you are required to submit an addendum, speaking to new relevant activities/achievements occurring since the last nomination was submitted.
Hidden
Addendum
If you nominated an individual for the last Award of Excellence and if you would like to proceed with nominating them again this year, you are required to submit an addendum, in the space provided, speaking to new relevant activities/achievements occurring since the last nomination was submitted.
Hidden
Please attached a filled out scanned copy of the signature page*
Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB.
By selecting 'yes' below the nominator, confirms that this submission is an endorsement of the nominee and confirms there is no evidence to support why this person should not be considered for an award.*
- Yes, I fully endorse the nominee and confirm that there is no evidence to support why this person should not be considered for this award
Submitting nomination online is deemed to be an electronic signature
Part Two
In order to objectively evaluate and select an award recipient, the Members of the Awards Committee ask that you provide relevant information based on consistent selection criteria. We encourage you to also include personal stories, or stories from patients, families, etc., and examples that highlight the nominees’ outstanding contribution.

Award Eligibility: The nominee is an exemplary CHPCA associate / provincial member whose excellence is devoted to hospice palliative care in Canada, in either a paid or voluntary capacity. To be a recipient of this award, the nominee must have made an impact at the national level and contributed to the mission of CHPCA by enhancing the quality of life for individuals and their loved ones who are facing a life-threatening illness and bereavement.

The Awards Committee’s assessment of the nominees’ overall contributions will be guided by the following criteria:
• General accomplishment in the field of hospice palliative care
• Level of commitment, both personal and/or professional, to hospice palliative care
• Contribution as a volunteer and support for volunteer initiatives in service of advancing hospice palliative care in Canada
• Leadership in areas of hospice palliative care program development, policy and advocacy
• Development and involvement in hospice palliative care educational initiatives
• Community hospice palliative care outreach and development
• Advancement of hospice palliative care best practice in areas such as interdisciplinary team capacity building and service delivery
• Impact on end-of-life care research and/or quality improvement initiatives

Based on the above recipient criteria, please completely answer all of the following questions, using the space provided below.

The CHPCA reserves the right to disqualify any nomination that does not completely and thoroughly answer all of these questions.
Please describe the nominee's personal and/or professional achievement and commitment to hospice palliative care in Canada. Please include type of service and length of service (max. 300 words)*
Please list any relevant organizations or committees (including the level of scope: local, provincial or national) the nominee has participated in as a full member.
First Committee Name*
Number of years served on this committee*
Scope of the Committee*
- Local
- Provincial
- National
Second Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Third Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fourth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fifth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Sixth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Seventh Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Eighth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Ninth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Tenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Eleventh Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Twelfth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Thirteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fourteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fifteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Please describe the impact the nominee has made in the lives of patients and their families. (max. 300 words)*
Please describe the contributions the nominee has made to advance quality of life and hospice palliative care in their local community (max. 200 words)*
Please describe the contributions the nominee has made to foster quality hospice palliative care at the provincial level ( max. 200 words)*
Please describe the contributions the nominee has made to improve hospice palliative care in Canada (max. 200 words)*
Please describe the contributions the nominee has made to represent the Canadian Hospice Palliative Care Community on the global stage, among international audiences (max. 200 words) (optional)
Please describe the nominee's contributions to hospice palliative care education (e.g. mentoring, developing curriculum and teaching, etc.) (max. 200 words)*
Please describe the nominee's contributions to the field of hospice palliative care research and/or quality improvement initiatives (e.g.) clinical research, developing protocols and standards, publishing journal articles etc.) (max. 200 words)*
Please attach AT LEAST two independent letters of support from colleagues or peers that clearly describes the nominee's accomplishments, leadership, and commitments related to hospice palliative care*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 10.
Please attach an electronic copy of a recent picture (head and shoulders) of the nominee suitable for promotional purposes related to the CHPCA's Award of Excellent (*jpeg, jpg, png, or gif format preferred)*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 3.
Please include a copy of the current CV of the nominee (Please note: the nominee's CV should be limited to 5 pages maximum)*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 2.
If the nominee is NOT selected as a recipient of the CHPCA's Award of Excellence, would they grant permission to the CHPCA to recognize their name and nomination during the Award of Excellence Ceremony and/or in other recognition and/or promotional materials related to the Award of Excellence*
- No, the nominee does not wish for their name to be mentioned at the award ceremony or as any part of recognition or promotional materials.
- No, the nominee does not wish for their name to be mentioned at the award ceremony or as any part of recognition or promotional materials.
- Yes, the nominee give permission for their name to be recognized during the award ceremony only.
- Yes, the nominee give permission for their name to be recognized during the award ceremony only.
Consent*
In making this nomination, I have confirmed that the nominee is willing to allow their name to stand for this award and that they are a CHPCA associate / provincial member in good standing of the CHPCA.

Save and Continue Later

Nomination Submission Form
The 2023 Deadline for Submission is September 1, 2023

Questions on submission of award nomination should be directed to [email protected]
Part One
Name of Nominee*
First Last
Is the nominee a current CHPCA Associate/Provincial Member?*
- Yes
- No
(Note: Nominee must have been a CHPCA Associate/Provincial Member for the past year and maintain current CHPCA Associate/Provincial Member status)
Address of Nominee*
Street Address Address Line 2 City Province Postal Code
Nominee's Home Phone No.*
Nominee's Daytime Phone No.*
Nominee's Email*
Hospice/Palliative Care Service or Program:*
Name of Nominator*
First Last
Is the nominator a CHPCA Associate/Provincial Member in good standing?*
- Yes
- No
(Note: Nominator must have been a CHPCA Associate/Provincial Member for the past year and maintain current CHPCA Associate/Provincial Member status)
Address of Nominator*
Street Address Address Line 2 City Province Postal Code
Nominator's Home Phone No*
Nominator's Daytime Phone No*
Nominator's Email
Did the nominator submit a nomination for this nominee during the last CHPCA Award of Excellence call for submissions?*
- No, the nominator did not submit a nomination for this nominee during the past award submission
- Yes, the nominator did submit a nomination for this nominee during the past award submission
The last call for submissions was for the 2019 Award of Excellence
The CHPCA Awards Committee is offering you the opportunity to allow a past nomination to stand for this year’s Award of Excellence. If you nominated an individual for the 2022 Award of Excellence and if you would like to proceed with nominating them again this year, you must fill out Part One of the Nominations form and you must contact the nominee and have them resign the Nominations Application Requirements Checklist and Signatures form. You must also ensure that their CHPCA associate / provincial membership is up-to-date. You do not need to resubmit Part Two of the application; however, you are required to submit an addendum, speaking to new relevant activities/achievements occurring since the last nomination was submitted.
Hidden
Addendum
If you nominated an individual for the last Award of Excellence and if you would like to proceed with nominating them again this year, you are required to submit an addendum, in the space provided, speaking to new relevant activities/achievements occurring since the last nomination was submitted.
Hidden
Please attached a filled out scanned copy of the signature page*
Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB.
By selecting 'yes' below the nominator, confirms that this submission is an endorsement of the nominee and confirms there is no evidence to support why this person should not be considered for an award.*
- Yes, I fully endorse the nominee and confirm that there is no evidence to support why this person should not be considered for this award
Submitting nomination online is deemed to be an electronic signature
Part Two
In order to objectively evaluate and select an award recipient, the Members of the Awards Committee ask that you provide relevant information based on consistent selection criteria. We encourage you to also include personal stories, or stories from patients, families, etc., and examples that highlight the nominees’ outstanding contribution.

Award Eligibility: The nominee is an exemplary CHPCA associate / provincial member whose excellence is devoted to hospice palliative care in Canada, in either a paid or voluntary capacity. To be a recipient of this award, the nominee must have made an impact at the national level and contributed to the mission of CHPCA by enhancing the quality of life for individuals and their loved ones who are facing a life-threatening illness and bereavement.

The Awards Committee’s assessment of the nominees’ overall contributions will be guided by the following criteria:
• General accomplishment in the field of hospice palliative care
• Level of commitment, both personal and/or professional, to hospice palliative care
• Contribution as a volunteer and support for volunteer initiatives in service of advancing hospice palliative care in Canada
• Leadership in areas of hospice palliative care program development, policy and advocacy
• Development and involvement in hospice palliative care educational initiatives
• Community hospice palliative care outreach and development
• Advancement of hospice palliative care best practice in areas such as interdisciplinary team capacity building and service delivery
• Impact on end-of-life care research and/or quality improvement initiatives

Based on the above recipient criteria, please completely answer all of the following questions, using the space provided below.

The CHPCA reserves the right to disqualify any nomination that does not completely and thoroughly answer all of these questions.
Please describe the nominee's personal and/or professional achievement and commitment to hospice palliative care in Canada. Please include type of service and length of service (max. 300 words)*
Please list any relevant organizations or committees (including the level of scope: local, provincial or national) the nominee has participated in as a full member.
First Committee Name*
Number of years served on this committee*
Scope of the Committee*
- Local
- Provincial
- National
Second Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Third Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fourth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fifth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Sixth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Seventh Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Eighth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Ninth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Tenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Eleventh Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Twelfth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Thirteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fourteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Fifteenth Committee Name
Number of years served on this committee
Scope of the Committee
- Local
- Provincial
- National
Please describe the impact the nominee has made in the lives of patients and their families. (max. 300 words)*
Please describe the contributions the nominee has made to advance quality of life and hospice palliative care in their local community (max. 200 words)*
Please describe the contributions the nominee has made to foster quality hospice palliative care at the provincial level ( max. 200 words)*
Please describe the contributions the nominee has made to improve hospice palliative care in Canada (max. 200 words)*
Please describe the contributions the nominee has made to represent the Canadian Hospice Palliative Care Community on the global stage, among international audiences (max. 200 words) (optional)
Please describe the nominee's contributions to hospice palliative care education (e.g. mentoring, developing curriculum and teaching, etc.) (max. 200 words)*
Please describe the nominee's contributions to the field of hospice palliative care research and/or quality improvement initiatives (e.g.) clinical research, developing protocols and standards, publishing journal articles etc.) (max. 200 words)*
Please attach AT LEAST two independent letters of support from colleagues or peers that clearly describes the nominee's accomplishments, leadership, and commitments related to hospice palliative care*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 10.
Please attach an electronic copy of a recent picture (head and shoulders) of the nominee suitable for promotional purposes related to the CHPCA's Award of Excellent (*jpeg, jpg, png, or gif format preferred)*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 3.
Please include a copy of the current CV of the nominee (Please note: the nominee's CV should be limited to 5 pages maximum)*
Drop files here or

Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 2.
If the nominee is NOT selected as a recipient of the CHPCA's Award of Excellence, would they grant permission to the CHPCA to recognize their name and nomination during the Award of Excellence Ceremony and/or in other recognition and/or promotional materials related to the Award of Excellence*
- No, the nominee does not wish for their name to be mentioned at the award ceremony or as any part of recognition or promotional materials.
- No, the nominee does not wish for their name to be mentioned at the award ceremony or as any part of recognition or promotional materials.
- Yes, the nominee give permission for their name to be recognized during the award ceremony only.
- Yes, the nominee give permission for their name to be recognized during the award ceremony only.
Consent*
In making this nomination, I have confirmed that the nominee is willing to allow their name to stand for this award and that they are a CHPCA associate / provincial member in good standing of the CHPCA.

Save and Continue Later

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