School Nurse Leadership Award and Application Draft.docx



Healthy Schools Campaign

School Nurse Leadership Award Application

Sponsored by School Health Corporation and Maico Diagnostics

Type your responses in the spaces provided below. When you save the document, name the file using your first last name, first name and 2016-SNLA (e.g., doe-jane-2016-snla.doc). You may complete the application if you are a school nurse or if you wish to recognize a school nurse in your school or district.

Send the application and additional materials as e-mail attachments to snla@. The subject line should read: “First Name Last Name, 2016 SNLA.” Applications are due by March 8, 2016. More information about the award can be found at leadership-award.

Your submission should include the following:

1) This application (required). Please name the file “lastname-firstname-2016-snla”.

2) Letter of Support (required). Please provide a copy of a letter of support for the application from your/the school nurse’s current or past principal or administrator. Please name the file “lastname-firstname-letter-of-support”.

3) Photos. Please submit at least one photo showing your work in action. Photos of you with students, coworkers, or at your desk are great! Photos should be high-resolution, at least 850x520 pixels. Please name the file “lastname-firstname-photo.”

Applicant information

|Applicant Name | |

|Title | |

| Direct Phone | |

|School Phone | |

|Primary E-mail Address | |

|Secondary E-mail Address | |

|Fax | |

|Number of students/buildings | |

|responsible for | |

If you are applying on behalf of someone:

|Your Name | |

|Relationship to Applicant | |

|Phone | |

|E-mail Address | |

School Information (if more than one, select one school)

|School Name | |

|Address | |

|City, State, ZIP | |

|Setting (urban, suburban, rural, | |

|etc.) | |

|Number of Students | |

|Percentage of students on free or | |

|subsidized lunch (if applicable) | |

About School/District

|School/District Name | |

|Number of Students | |

|Percentage of students on free or | |

|subsidized lunch | |

|Type of School (elementary, high | |

|school, district, etc.) | |

Applicant Supervisor

|Supervisor Name | |

|Title | |

|Phone | |

|Email | |

Applicant Administrator

|Administrator Name | |

|Title | |

|Phone | |

|Email | |

Background and Experience (if you are applying on behalf of someone, please complete the following questions with their information)

|What is your current role in your school/district? | |

|How many schools do you serve? | |

|How many years have you worked as a school nurse? | |

|What other nursing experience do you have? | |

|What is your educational | |

|background (i.e. degrees)? | |

|Does your state have school nurse certification? If so, are you a | |

|certified school nurse in your state? | |

|Are you a nationally certified school nurse? | |

|List any school and/or community committees, boards, coalitions in | |

|which you participate. | |

|List any professional affiliations. | |

|List professional journals you regularly read. | |

|Briefly describe your participation in continuing education in the | |

|past two years. | |

When answering the questions below, please focus your narrative on the applicant’s efforts more than the health conditions in your community served. While context matters, our judging panel will primarily want to discuss the work accomplished by the applicant.

Your Story (if you are applying on behalf of someone, please complete the following questions with their information) Please answer the question below in 350 words or less.

|Share why you (or the applicant) exhibit elements of a school health leader. |

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Please answer at least two of the following three questions in 350 words or less.

|1) Share an example of your (or the applicant’s) implementation of an evidence-based intervention that impacted health outcomes for your |

|student population. |

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|2) Share an example of how you (or the applicant) lead and/or participate on a team to address health issues in your school/district. |

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|3) Share an example of how you (or the applicant) advocated for policy change at your school, district or state to improve the health of |

|your students. |

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