Nomination Form

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Prevent, Detect, Support. For health professionals in the Australian community who inspire us! Nomination Form. Kidney H
Mar 2016

Prevent, Detect, Support.

For health professionals in the Australian community who inspire us!

Nomination Form

Kidney Health Australia Awards for Excellence in Early Detection of Kidney Disease in Primary Care

Nominee Details Title

Mr

Ms

Miss

Dr

Prof.

Name

Surname

Organisation Address Suburb Telephone

State Work

Postcode

Mobile

Email Category

GP practice

GP

Primary Care nurse

Other:

I am nominating: Myself - a  third party written reference must be included with your submission. Someone else - please ensure you complete your contact details below, on this page. 

Local Media Details It may be helpful for us to know who the nominee’s local media is. Please advise us of the most popular local: Newspaper

Radio

Definition of Excellence (nominees should meet at least two of these criteria) • Maintain a patient register for chronic disease (including CKD), with a recall and reminder system for patients eligible for assessment and those who require management of risk • Regularly audit practice records for proportion of eligible patients who are checked, who have their risk managed according to the relevant practice guidelines, who have a GP management plan, and who accessed evidence-based prevention programs. • Build systems to maintain the accuracy of these registers over time • Have a system in place to identify individuals at risk of developing CKD and procedures to ensure kidney health check is performed • Provide CKD patients with relevant information/resources to encourage self-management • Champion (individual nominee) or take an all of practice approach (team nominee) involving a multidisciplinary team approach to detecting and managing Chronic Disease including CKD • Take an integrated care approach to managing CKD in conjunction with diabetes and cardiovascular disease in their practice

Your Details Title

Mr

Mrs

Miss

Dr

Name

Prof. Surname

Address Suburb Telephone

State Work

Postcode

Mobile

Email Relationship

Connect with us

(to the person being nominated).

www.kidney.org.au

Freecall 1800 454 363

Mar 2016

Prevent, Detect, Support.

Declaration - MUST BE SIGNED BY THE PERSON BEING NOMINATED FOR THE AWARD I have read the Primary Care Awards Guidelines (page 4) and I include with this nomination, a 500 words (maximum) submission, one photo and one written reference to support the nomination. (NB reference only required if you are nominating yourself). All the information supplied is true and correct. I acknowledge that the decision of the judging panel is final and no further discussion will take place. I give permission to Kidney Health Australia to use both the photo and the story outlined in the submission for any media/public announcement should my nomination as a 2016 Primary Care Awards Recipient be successful.

Nominee Name Nominee Signature



Date

Please check before submitting: Nomination form fully completed Declaration (above) signed and dated Photo ( Completed and signed nomination form > Submission (maximum 500 words) > Photo ( Written Reference (only required if you are nominating yourself) Email

[email protected]

Postage

Primary Care Kidney Health Australia GPO Box 9993 Adelaide SA 5001

Connect with us

www.kidney.org.au

Freecall 1800 454 363

Mar 2016

Prevent, Detect, Support.

Kidney Health Australia Primary Care Award Submission Typed submissions may be attached here. Hand written submissions (please print clearly) will also be accepted. Please note submissions should be no greater than 500 words. Please highlight how the nominee meets any criteria in the definition of excellence.

Connect with us

www.kidney.org.au

Freecall 1800 454 363

Mar 2016

Prevent, Detect, Support.

Primary Care Awards Guidelines 1. The nominee may be an individual, or an organisation and will represent one of the following categories:

Health professional working within the screening and diagnosis community



Organisation providing screening and diagnosis for those with early kidney disease

2. The nominee (or the person nominating someone else) will write a short submission of no more than 500 words. This submission will include the following: Who the person is and which category the y represent. If the nominee is Aboriginal, Torres Strait Islander or from another culturally and linguistically diver se background, please mention this. What the person or organisation doe s that addresses the definition of excellence When this outstanding contribution has taken place or continue s to take place. Has it been over a long period of time or has it been a one-off major contribution? Where this person has dedicated themselves to outstanding work in kidney health. Is it in a metropolitan, regional, rural or remote area of Australia? How the person’s dedication to kidney health in Australia has made an impact. Why this person/organisation should be awarded a Kidney Health Australia Primary Care Award. 3.  If a person is nominating themselves, they must provide one written reference to support the nomination, in addition to their 500 words submission. The reference may be completed by a health professional, or work colleague but not by a member of staff at Kidney Health Australia.  IIf you are a person nominating someone else however, you are not required to submit a written reference for that person as your nomination of them is deemed sufficient. 4.  There is no age limit. 5.  Aboriginal people, Torres Strait Islander people and others from culturally and linguistically diverse backgrounds are encouraged to nominate or be nominated. 6.  People living in remote, rural, regional and metropolitan Australia are encouraged to nominate or be nominated. 7.  The Primary Care Awards judging pane l decision is final and no discussion will be entered into. 8.  Primary Care Awards are only awarded once and previous recipients are not eligible to nominate again. Unsuccessful applicants are encouraged to re-apply the following year. 9.  State finalists will be nominated for the national awards. 10.  A recent photograph must accompany the nomination. Please send a digital photo, not exceeding 4Mb, which you would be happy to have published. Photographs will not be returned. 11. Primary Care nominations open on Monday 4th April 2016 and will be received until midnight on Saturday 1 May 2016. Late applications will not be considered. 12.  All nominees agree to give permission, for both their photo and the story in their nomination, to be shared publicly on the occasion that they are announced Primary Care Award recipient. This public announcement may include the KHA website, Kidney Community newsletter, and mainstream media such as local newspapers, daily newspaper s, radio and television. 13.  For enquiries regarding Primary Care Awards, please contact Christine Delaine on 08 8334 7512 or email [email protected].

Connect with us

www.kidney.org.au

Freecall 1800 454 363