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 up to 250 words why your nominee should receive an award.  When writing your statement please keep in mind why they are deserving of an awards, and how it relates to the Trust value you have selected. Please note if the word count is exceeded only the first 250 words will be used.

12. Please confirm you are happy for Barts Health to contact you about your nomination

Thank you for taking the time to submit your nomination.