Shine a Light Award - Nomination Form

Please fill out the form below. * required information

Name of individual or team*:

Email of individual or team*:

Their job title:

Their service/department/location (if known):

Description of action that made a difference*:

Date the action occurred:

About you:

Your name*:

Are you:

a patient/service user

a relative or friend of a patient/service user

a member of Trust staff

other (please outline below)

If the nominee is successful and receives an award would you like to be advised, involved in publicity and/or attend their presentation? Please add your preferred contact details below and also include a telephone number if possible:

Your address:

Your email*:

Tel no: