Moorfields' Stars staff nomination form

Moorfields’ Stars is back for another year to celebrate staff achievements.

Thank you for taking the time to recognise the great work colleagues across the trust are doing. Please complete the questionnaire below and don't forget to press 'done' when you're finished.

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* 1. Your name

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* 2. Your job title

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* 3. Your contact details (email or mobile number)

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* 4. Are you staff at:

Moorfields

UCL Institute of Ophthalmology

Other

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* 5. We are asking for your contact details so that we can get in touch should we need additional information from you. Your contact details will not be used for any other purpose, shared without your express permission and will be deleted once the nomination process has been completed.

If your nominee is shortlisted, we may contact you to ask if you would be happy to appear in a short video interview. Would you be willing to be filmed?

Yes

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* 6. Please tick the award that you are nominating an individual or team for:

Moorfields’ star of the year award

Moorfields' team of the year award

Moorfields Eye Charity award for innovation and service improvement

Moorfields’ volunteer of the year award

Moorfields’ leadership award

Moorfields’ unsung hero award

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* 7. Please complete the appropriate section below depending on whether you are nominating a team or an individual for an award.

Individual nominee's name

Individual nominee's job title

Individual nominee's department

Individual nominee's contact number

Individual nominee's email address

Team name

Team leader's name

Team leader's telephone number

Team leader's email address

Team's location

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* 8. What action did the nominee(s) take that has made you want to nominate them?

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* 9. When did the nominee(s) take this action?

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* 10. How does this action go above what’s involved in the nominee(s)’s daily role?

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* 11. How has this action positively impacted on our patients/colleagues/the trust?

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* 12. What evidence have you got to illustrate the positive impact this action has had?
Where possible, use factual examples of improvements including patient feedback (statements/comments), clinical outcomes or financial reports.

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* 13. Which of The Moorfields Way values did the nominee(s) demonstrate?

Caring

Excellent

Inclusive

Organised

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* 14. Which of the Moorfields strategic objectives has the nominee(s) helped to deliver?

We will pioneer patient-centred care with exceptional clinical outcomes and excellent patient experience.

We will be at the leading edge of research, making new discoveries with our partners and patients.

We will innovate by sharing our knowledge and developing tomorrow’s experts.

We will collaborate to shape national policy.

We will attract, retain and develop great people.

We will have an infrastructure and culture that supports innovation.

We will have a sustainable financial model.

We will be enterprising to support and fund our ambitions.

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* 1. Your name

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* 2. Your job title

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* 3. Your contact details (email or mobile number)

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* 4. Are you staff at:

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* 6. Please tick the award that you are nominating an individual or team for:

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* 7. Please complete the appropriate section below depending on whether you are nominating a team or an individual for an award.

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* 8. What action did the nominee(s) take that has made you want to nominate them?

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* 9. When did the nominee(s) take this action?

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* 10. How does this action go above what’s involved in the nominee(s)’s daily role?

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* 11. How has this action positively impacted on our patients/colleagues/the trust?

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* 12. What evidence have you got to illustrate the positive impact this action has had?Where possible, use factual examples of improvements including patient feedback (statements/comments), clinical outcomes or financial reports.

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* 13. Which of The Moorfields Way values did the nominee(s) demonstrate?

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* 14. Which of the Moorfields strategic objectives has the nominee(s) helped to deliver?

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* 15. In no more than 300 words, please summarise your reasons for nominating this individual/team.

* 12. What evidence have you got to illustrate the positive impact this action has had?
Where possible, use factual examples of improvements including patient feedback (statements/comments), clinical outcomes or financial reports.