Please complete this short form with the details of the individual/team you are nominating. At the end you will be asked to write up to 250 words as to why they deserve an award - this information will be used to help the short listing panel make their decision.

1. What is your name?

2. Please provide your contact details:

3. Are you nominating an individual or a team?

4. What is the name of individual/team you wish to nominate (Please note you cannot nominate yourself and the nomination must be for Barts Health staff or one of our partner organisations)

5. If you are nominating a team please provide the name of a team member whom we can contact

6. If you are nominating an individual please provide their job title?

7. What value are you nominating the team/individual for?

8. Please tell us how you are known to the individual/team:

9. Which site does the individual/team work at?

10. Which department do they work in?

11. Please tell us in no more than 250 words why this team/individual should receive this award. Please note if the word count is exceeded only the first 250 words will be used. When writing your statement you might find it helpful to keep in mind what makes them stand out.

Thank you for taking the time to submit your nomination.

T