Nominee Details

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.

Question Title

* 1. About you:

Question Title

* 2. Are you nominating an individual or a team?

Question Title

* 3. What is the first name of individual/team you wish to nominate (NB: the nomination must be for Barts Health staff or one of our partner organisations, and we cannot accept self nominations for individuals)

Question Title

* 4. What is the last name of individual you wish to nominate

Question Title

* 5. If you are nominating an individual, please provide their email address if known:

Question Title

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

Question Title

* 7. If you are nominating a team please provide the name/email of a team member we can contact:

Question Title

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

Question Title

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

Question Title

* 10. Which site does the individual/team work at?

Question Title

* 11. Which department do they work in?

Question Title

* 12. 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.

Question Title

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

Thank you for taking the time to submit your nomination.

T