2024 Brenda Smith Leadership Award Nomination Form

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* 1. Nominee Information

Name

Title or Role

Phone Number

Email Address

Employer/Agency

Mailing Address

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* 2. Nominator #1 Information

Name

Title or Role

Phone Number

Email Address

Relationship to Nominee

Employer/Agency

Mailing Address

Question Title

* 3. Nominator #2 Information

Name

Title or Role

Phone Number

Email Address

Relationship to Nominee

Employer/Agency

Mailing Address

Please answer all of the following questions about the nominee. For each question, please provide a detailed description with specific examples about the way in which the nominee excels in each area. The score for each question is dependent on the details and examples provided about the nominee. The more evidence and examples provided for each question, the higher the potential score. Insufficient detail or examples for each question will result in a lower score. Responses should be limited to a maximum of 400 words for each question. The maximum score possible for each answer is listed after each question.

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* 4. Describe how the nominee excels in providing or ensuring the provision of quality hospice palliative care to the client/patient and their chosen family. (Refers to care of the client/patient and family). Maximum score of 30. **Please refer to the following document from the Ontario Palliative Care Network regarding expected palliative care competencies: Ontario Palliative Care Network Competency Framework

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* 5. Describe how the nominee demonstrates leadership in advancing and/or improving the provision of hospice palliative care (within the unit or team, organization, or region). Maximum score of 30.

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* 6. Describe how the nominee demonstrates the importance of lifelong learning and mentorship in the provision of quality hospice palliative care (for themselves, others, and system wide). Maximum score of 30.

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* 7. Describe how the nominee works to support and/or empower other members of the hospice palliative care team. Maximum score of 30.

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* 8. Brenda sent energy and momentum outwards like the ripples created when a pebble is thrown into a pond. The ripple effect of her great leadership and vision continues today to spread through this region and beyond to help build capacity and enhance quality of care.

Please provide any other relevant information regarding how the nominee demonstrates the spirit and characteristics of Brenda as described in the Call for Nominations. Maximum score of 10.