We may need to contact you for further information, so please provide your preferred contact information.

Please be aware that this form is hosted on a non-NHS site (www.surveymonkey.net) if you want to read more about their privacy policy and data security please visit their website www.surveymonkey.co.uk/mp/legal/privacy.

If you do not want to include your personal details on this form please submit your nomination via email to lhnt.lchsecomms@nhs.net.

This survey will ask you the following questions:

1.     Your name
2.     Your address (staff can provide work address)
3.     Your email address
4.     Contact telephone number
5.     Are you a: LCHS Staff member, Patient, Carer, Stakeholder or Member of the public.
6.     Which award are you nominating for?
7.     Name of the individual or team you wish to nominate
8.     Job title of the person you are nominating (if known)
9.     Where do they work (if known)
10. Briefly outline why the individual or a team you are nominating should receive this award (max 150 words)
11. How does your entry meet the criteria for the category you are entering? Please give examples of the individual/team work that you’d like to recognise with explanation (max 150 words)
12.  Are you happy to reveal your name to the person or a team you have nominated?

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* 1. Your name

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* 2. Your email address

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* 3. Contact telephone number

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* 4. Are you a