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 submissio
