I am a:

Visitor Staff member Other (please explain)

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First name:

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Surname:

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Contact details: (email or phone):

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If you are a Western Health staff member or volunteer

Role: _______________________________

Department: _________________________

• Drop this form into an Award box, or• Send to People Services, 5th Floor,

Footscray Hospital, or• Submit your nomination online:

email inspire@wh.org.au

ABOUT YOU

Would you like to say

THANK YOUto a staff member or volunteer?

The INSPIRE AwardsRecognising staff or volunteerswhose actions inspire othersto live our values

• Compassion• Accountability• Respect• Excellence• Safety

Nominate someone from Western Health for

an INSPIRE Award

Together, caring for the west

Name of person (or persons)

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What is their role?

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Where do they work (ward/unit and site)?

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Explain what they did which has made a difference to your experience or the experience of others. Please give an example and as much detail as you can.

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When did you observe this?

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Please note that we may share what you say as part of the Inspire Award process.

ABOUT THE PERSON OR TEAM YOU ARE NOMINATINGSay thank you to someone who has made a difference to your day or to the experience of others.

Nominate them for an INSPIRE Award.

You can nominate individuals or teams who demonstrate our values in their work, through:

Compassion• whoimprovetheexperienceofothers

Accountability• forstandardsofcareorservice

• beingpositiveandproductive

• usingresourcesresponsibly

Respect• communicatingrespectfullyinall situations

• recognisingandrespectingdiversity

Excellence•demonstratinghighstandardsofwork

• helpingotherslearnandimprove

• workingwellwithothers,acrossthesystem

Safety• lookingoutforthesafetyofothers

Anyone can nominate