Title : Nomination of Princess Srinagarindra Award 2019

              Call for the Nomination of 2019 Princess Srinagarindra Award

The Princess Srinagarindra Award Foundation (PSAF) under the Royal Patronage calls for the nomination of a nurse and/or midwife for the 2019 Princess Srinagarindra Award. The PSAF was established in commemoration of the Centenary Birthday Anniversary of Her Royal Highness Princess Srinagarindra Mahidol of Thailand on 21st October, 2000. The Princess Srinagarindra Award, to be conferred as an international award for an individual or group of registered nurses and/or registered midwives, is established in honour of her Royal Highness Princess Srinagarindra Mahidol and in recognition of her exemplary contribution towards progress and advancement in the field of nursing, midwifery and/or social services.
 
The national nursing authorities or individual or group of individual can nominate ONE  individual registered nurse and/or registered midwife or a group of registered nurses and/or registered midwives from each country who has made significant contribution for the development of the nursing and/or midwifery profession, health system and/or health and quality of life of the people. 

The information and nomination form is adhered below.

The nomination form and the required document in English must be submitted from now upto May 31st, 2019.

 
The 
Princess Srinagarindra Award

          

            I N F O R M A T I O N    &   N O M I N A T I O N   F O R M S

 

The Princess Srinagarindra Award Foundation was established on 21 October 2000 in commemoration of the Centenary Birthday Anniversary of Her Royal Highness Princess Srinagarindra Mahidol.

 

The Princess Srinagarindra Award, to be conferred as an international award on an individual or group of registered nurses and/or registered midwives, is established in honor of Her Royal Highness Princess Sringarindra Mahidol and in recognition of her exemplary contribution towards progress and advancement in the field of Nursing, Midwifery and Social Services

The required documents must be completed in English and received by the Foundation by May 31, 2019.

 

The Annex 1: the Eligibility Criteria and Selection Procedure

 

Each nominee for the Princess Srinagarindra Award must:

 

1.   Hold the qualification of Registered Nurse and/ or Registered Midwife of any country in the world;

2.   Be authorized to practice as a nurse or midwife in her/his own country or to have otherwise retired or resigned in good standing;

3.   Have made a significant contribution, through direct care, research, education or management, within the nursing and/or midwifery profession and/or for the development of the nursing and/or midwifery profession, health system and/or people’s health;

4.   Have made the contribution(s) during the years immediately preceding the award or as a cumulative effort that continues to the present time.

 

For Further Information:-

Please contact Princess Srinagarindra Award Foundation

Dr. Tassana  Boontong, RN., R.M. Ed.D., Ph.D. (Hon.)

Secretary-General, The Trustee of the Princess Srinagarindra Award Foundation

under the Royal Patronage,

Nagarindrasri Building, C/O Ministry of Public Health

Tiwanond Road, Amphur Muang, Nonthaburi 11000 THAILAND

Tel:  (662) 596-7580  Fax: (662) 965 9264, (662) 589-7121

 

For more information :-Please contact Princess Srinagarindra Award Foundation

http://www.princess-srinagarindraaward.org 

E-mail: psaf.rp@gmail.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The  Princess   Srinagarindra   Award

 

 
 

   Attach a recent

Photograph of the

nominee(s) with

name and date

marked on the back

 

 

 

 

 

 

 

 

 

 

 

 

NOMINATION   FORM

 

 

Before completing the Nomination Form, please read the brochure entitled “Princess Srinagarindra Award” and the Annex 1: the Eligibility Criteria and Selection Procedure”.

 

 

Notes:

a)   This form must be typed, and submitted as an original document, in English,                                       with original signatures in all places specified.

b)  In addition to an individual registered nurse and/or registered midwife,  a group of  no more than four (4) registered nurses and/or registered midwives who have worked together on the same specific project for a period of time and for which the outcomes have significant implications for nursing practice, education, health care or further research, may be nominated. Achievements must be submitted as a group performance while personal data must be completed by each member. 

c)   Nominations may be submitted by individual(s) or by organizations, referred to herein

     as sponsors.

d) The National Nurses Association, The Nursing Council and the Department of Nursing at

the Ministry of Health are the organizations at the country level who may be the sponsor.

e) Each of these entities should be aware of and support or have no objection to the nominee(s).

f)  A Curriculum Vitae of the nominee(s) should be attached as per Annex 1.

g)  The names of the nominee(s) must be submitted to the nominee’s National/State Nursing Council (NNC) or National/State Regulatory Authority (NRA) for certification. Please see Part VI.

h) One Country should nominate ONE person or ONE group for the Award.

i)  All forms and documents must be mailed to Princess Srinagarindra Award Foundation (PSAF) and received by PSAF no later than 31 May, 2019. Advance information can be sent by e-mail.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I:         THE NOMINATION                                                                                 

 

I/We hereby nominate for the Princess Srinagarindra Award 2019

 

                                                                                                                                                           

                                                                                  (Typed name of nominee(s))                                                                                 

 

Please check one:    individual sponsor   or      organizational sponsor

 

                                                                                                                                                           

 (Name of sponsor)

 

Relationship of sponsor to the nominee:                                                                                    

 

 

Address of sponsor:                                                                                                                                    

                                     (No.)                                             (Street)

 

                                                                                                                                                           

                       (City)                                                                                         (State/Province/County)

 

                                                                                                                                                           

                   (Post Code)                                                                                                          (Country)

 

Phone number:                                                    Fax number:

 

                                                                                                                                                           

       (Country Code/Area Code/Number)                                    (Country Code/Area Code/Number)

 

Website:                                                           Email address: 

 

                                                                                                                                                           

 

 

Signature of individual sponsor or authorized representative of organizational sponsor:

 

 

                                                                                                                                                           

                                          Signature                                                                                 Date

 

                                                                                                                                                           

                                   (Typed name)                                                                       (Typed title)

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

The  Princess   Srinagarindra   Award

 

PART II:  NOMINEE PROFILE

 

A.     Nominee’s Personal Data

 

Name:                                                                                                                                                                

                   (First Name)                           (Middle Name)                                (Family Name)

 

Preferred title: qMr.    qMrs.    qMs.    qMiss    qDr.      qOther                                                            

 

Date of Birth:            Nationality:                 Official Language:                                   

                       (Month/Day/Year)

 

Home Address:                                                                                                                   

                                           (No.)                                                                       (Street)

 

                                                                                                                                                           

                     (City)                                                                          (State/Province/Country)

 

                                                                                                                                                           

                        (Post Code)                                                                                  (Country)   

 

Mailing address if different from home address:

                                                                                                                                                     

                              (No.)                                                                           (Street)

 

                                                                                                                                                           

                     (City)                                                                          (State/Province/Country)

 

                                                                                                                                                           

                        (Post Code)                                                                                  (Country)

 

Home Phone:                                                     Home/office Fax:

                                                                                                                            

       (Country Code/Area Code/Number)                                    (Country Code/Area Code/Number)

 

Mobile phone:                                              Email address

                                                                                                                            

 

B.     Nominee’s Employment (if applicable):

 

Name of Organization:                                                                                                                 

 

Address                                                                                                                                         

                                           (No.)                                                                (Street)

 

                                                                                                                                                           

                           (City)                                                                        (State/Province/Country)

 

                                                                                                                                                           

                        (Post Code)                                                                                           (Country)

Office Phone:                                                   Fax:

                                                                                                                            

       (Country Code/Area Code/Number)                                    (Country Code/Area Code/Number)


 

 

The  Princess   Srinagarindra   Award

 

PART III:  SPONSOR STATEMENT

 

To be completed by the individual or organization making the nomination

 

Name:                                                                                                                                    

                              (Individual or organization making the nomination)

 

In your view, please comment briefly on the reason for the nomination, including the nominee’s work or contribution to the work, the outcome and the significant impact of this work for the development of the nursing and/or midwifery profession and improvement of the quality of life and health of the people. One additional page may be added.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of individual sponsor or authorized representative of the organizational sponsor          (this must be the same person who signed in Part I):

 

 

         .                                                            .             .                                                .        

                         Signature                                                                                    Date

 

 

 

 

The  Princess   Srinagarindra   Award

 

PART IV:  NOMINEE STATEMENT

 

State in concise terms the significant contribution or impact you have made, within the nursing and/or midwifery profession, and/or for the development of the nursing and or midwifery profession and quality of life and health of the people. One additional page can be added.

 

Please complete your Curriculum Vitae in Annex 1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I/We hereby consent to have my/our nomination submitted for the Princess Srinagarindra Award

 

 

                                                                                                                       

                                    Signature                                                                                Date

 

                                                                                                                       

                                 Signature                                                                                Date

   

                                                                                                                      

                                 Signature                                                                                Date

 

 

 

The  Princess   Srinagarindra   Award

 

PATR V:  OTHER ENTITIES AWARE OF/ SUPPORT OR HAVE NO              

                  OBJECTION TO THE NOMINATION

 

To be completed by the National Nursing/Midwifery Office, President of the Nursing/ Midwifery Council or President of the Nurses’ or Midwives’ National Association (It must be signed by 2 organizations other than the nominating one, where these exist)

 

I have been informed about the nomination of                                                                                                                                 

                                          (Nominee’s name)

 

by                                                                                                                                                         

(Name individual or organization sponsoring the nomination)

 

 

to receive the Princess Srinagarindra Award and have no objection.

 

                                                                                                                                                           

 

 

Name (print)                                                            

            (National Nursing/Midwifery Officer)

 

(Signature)                                                                 

 

Date                                          

 

 

Name (print)                                                            

                                                                      (President of Nursing/Midwifery Council)

 

(Signature)                                                                 

 

Date                                          

 

 

Name (print)                                                            

                                                           (President of Nurses’ or Midwives’ Association)

 

(Signature)                                                                 

 

Date                                          

 

 

 

 

 

 

 

 

 

The  Princess   Srinagarindra   Award

 

PART VI: CERTIFIED STATEMENT

 

The application must be certified by National/State/Provincial Nursing Council (NNC) or National/State/Provincial Regulation Authority (NRA).

 

Name of the National/State/Provincial Council or National/State/Provincial Regulation Authority

 

                                                                                                                                               

 

Address                                                                                                                                 

                                     (No.)                                                                                  (Street)

 

                                                                                                                                               

                                    (City)                                                                           (State/Province/Country)

 

                                                                                                                                               

                                (Post Code)                                                                           (Country)

 

Phone number:                                                    Fax number:

                                                                                                                                                           

       (Country Code/Area Code/Number)                                    (Country Code/Area Code/Number)

 

Website:                                                           Email address: 

                                                                                                                                                           

 

 

We hereby certify that                                                                                                       

                                                                        (Name of nominee)

 

is a Registered Nurse (first level) or Registered Midwife and a current member of our NNC or NRA or is retired or has resigned with good standing. (we should add an asterisk here and define good standing.)

 

Signature of the President, Executive Director, or other duty authorized representative of the NNC or NRA.

 

                                                                                                                                               

                                  Signature                                                                  Date

 

                                                                                                                                               

                             (Typed name)                                                              (Typed title)

 

 

All part of these forms must be completed in English, in full, signed where indicated,

and returned to Princess Srinagarindra Award Foundation

to arrive no later than  May 31, 2019

Princess Srinagarindra Award Foundation (PSAF)

Nagarindharasri Building,

  C/O Thailand Nursing and Midwifery Council C/O Ministry of Public Health

Tiwanon Road, Amphur Muang, Nonthaburi 11000,

 THAILAND.

 

 

 
 

The Annex 1: the CV document

 

 

 

 

The  Princess   Srinagarindra   Award

 

 

CURRICULUM VITAE

 

A.     Full name of the nominee (in capital letters) as it appears in your passport or on your birth certificate.

Name :                                                                                                                                                     

                   (First Name)                                             (Middle Name)                                (Family Name)

 

B.     Educational background: identify year of graduation, diploma(s)/degree(s), school/university, country. Please start with lowest to highest qualification in relation to nursing and midwifery.

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

 

C.    Working experience:  identify year, position, place of work. Please start from the current one.

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

 

 

The  Princess   Srinagarindra   Award

 

 

D.    Administrative position (if any), years in the position, workplace

 

Years

Position

Workplace

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.     Awards: The year you received the award, name of the award, the award recognition (on what achievements), and organization giving the award.

 

Year

Name of the Award/recognition

 

In recognition of

Organization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The  Princess   Srinagarindra   Award

 

F.     Research publication: List not more than 10 key research reports or publications.

A research report: identify name of author, year, title, place of printing, country.

An article: identify name of researcher, year of published, title of the article, name of the journal, journal number and pages.

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

 

 

G.    Book publication: authors, year of publication, title of the book, city where the book was printed, name of printing company. (list not more than 5 key books)

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

                                                                                                                                                           

 

 For More Details Click

All part of these forms must be completed in full, signed where indicated,

and returned to Princess Srinagarindra Award Foundation

to arrive no later than  May 31.

Princess Srinagarindra Award Foundation (PSAF)

Nagarindharasri Building,

  C/O Thailand Nursing and Midwifery Council C/O Ministry of Public Health

Tiwanon Road, Amphur Muang, Nonthaburi 11000,

 THAILAND.