Nominator CHPCA Board Member Submitting Nomination Form * Email of Submitter *
Nominee Name of Nominee * Address
* Email *
Home or Cell Phone Daytime or Work Phone Has the nominee been made aware they are being submitted for consideration for the Balfour Mount Champions Award? * 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) * Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, , Max. file size: 64 MB.
Please include a copy of the current CV of the nominee (Please note: the nominee's CV should be limited to 5 pages maximum) * Accepted file types: doc, docx, odt, pdf, rtf, tex, txt, wks, wps, wpd, jpg, jpeg, gif, png, Max. file size: 64 MB.
Balfour Mount Champion Award: Eligibility Criteria Please ensure that the nominee meets the following criteria prior to submitting the nomination form for consideration by the CHPCA Board.
The nominated individual, company or organization has fulfilled the following criteria:
-Shows the qualities of being a national champion for hospice palliative care by engaging in collaboration and partnerships, influencing change, networking, and/or storytelling and communications efforts and initiatives.
-Contributes to the advancement of hospice palliative care by demonstrating clear, compelling goals toward improving access, awareness, or leading advancements in hospice palliative care through the creation of innovative programs, and contributions to goals and standards for hospice palliative care.
-Demonstrates knowledge in hospice palliative care in a way that promotes programs and services, research, education, and/or knowledge translation through education, innovation, and publishing.
-Is a leading in hospice palliative care by demonstrating characteristics of being a role model, guiding, training, educating, and mentoring, and/or representing palliative care nationally.
-Engages in public awareness activities and initiatives that promote hospice palliative care nationally and advance public policy.
-Is a Canadian citizen or a company or organization that operates primarily in Canada;
The candidate does not need to achieve all of the performance activities but must fulfil the spirit of the award criteria. A marking criterion determines the judging, and award recipients are chosen based on the highest marks earned for meeting performance guidelines as outlined below.
Presentation of Award It is preferred but not required that the nominee is in attendance at the CHPCA Opening Ceremonies to accept the award if selected. The 2023 National Conference opening ceremonies takes place at The Ottawa Marriott Hotel on October 12th, 2023 beginning at 2:15 PM.
Nominee Background Information Provide examples of how the individual, company, or organization has achieved the performance activity under each eligibility criteria area. N/A should be entered in the answer field if the nominee does not meet one of the performance activities.
1. Collaboration & Partnerships: Measurable achievements to improve or overcome a challenge in hospice palliative care through effective relationships with others. The work being completed is 2. Influencing Change: Shows exceptional leadership in championing change and/or creating a culture of change to influence or advocate for hospice palliative care. The work being completed is 3. Networking: Promoting hospice palliative care's purpose, principles, values, and impact on Canadians and the larger world so that the value of palliative care is increased or understood better. The work being completed is 4. Storytelling & Communication: Provide innovative approaches to conveying ideas or messages related to hospice palliative care using multiple mediums (words, illustrations, videos, etc.) and delivering them using various media (i.e., print, online, social media). The work being completed is Committed to Excellence: Contributes to the advancement of hospice palliative care by demonstrating clear, compelling goals toward improving access, awareness, or leading advancements in hospice palliative care in any of the following ways:
1. Creation of Programs: The development of innovative programs that aim to raise awareness about hospice palliative care implementation and access issues. The work being completed is 2. Goals/Standards: Making a difference in the lives of Canadians and their families facing life-threatening illness and bereavement through advocacy, promotion, creation, or implementation of goals and/or standards of care The work being completed is Knowledgeable: Demonstrates knowledge in hospice palliative care in a way that promotes programs and services, research, education, and/or knowledge translation in any of the ways described below:
1. Education: Contribution to building effective hospice palliative care practices through writing, speaking, teaching, and delivering public presentations The work being completed is 2. Innovation: Developing new ways of thinking about practice, delivery, communication, research, and other aspects of hospice palliative care that enhance Canadian understanding of relevant issues. The work being completed is 3. Publishing: Making a significant contribution to professional literature (as an example, has published highly respected articles; has been quoted widely in journals and books; has developed a body of work that has contributed to hospice palliative care) The work being completed is A Dedicated Leader: Leading hospice palliative care by demonstrating the following characteristics:
1. Guides, Trains, Educates, Mentors: Dedicated to teaching, mentoring, writing, speaking, blogging, and sharing hospice palliative care information with others. The work being completed is 2. Role Model: Lead by exemplifying the values and principles of hospice palliative care leadership in their own actions. The work being completed is 3. Represents Palliative Care Nationally: Achieves national impact through research, theory, principles, and practice in hospice palliative care. The work being completed is Please provide any other relevant information that would assist in considering this nomination. Do you (Board member submitting application) verify that the individual is a Canadian citizen or if a corporation, that they operate primarily within Canada? Phone
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