NYSHFA Volunteer of the Year Nomination Form 2023

The following criteria apply to all of the “Volunteer of the Year” categories:

• Nominations must be sent to NYSHFA no later than January 2, 2023
• Facilities entering nominations must be members in good standing with NYSHFA
• Nominees must have volunteered at least one full year at the nominating facility
• Winners in any category may not win in any two consecutive years
• Individuals or groups nominated in one category may not also be nominated in a separate category in the same year

Please complete ALL fields below before submitting for consideration.

FILL OUT YOUR NOMINATIONS ONLINE!👇

• 1. Please Select A Category:*
  Young Adult (ages 13 - 29)Adult (ages 30 - 64)Senior Adult (ages 65+)Group, Club or OrganizationSpiritual Guidance
  Select ONLY one category.
• 2. Name of Facility:*
• Phone:*
• *
  Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• 3. Name of Nominee / Group:*
  Please verify the EXACT name of nominee or group, as it will be used to make the awards.
• Contact Person for the Group:*
  First Last
• Phone:*
• *
  Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• 4. If Nominee is a Teenager, Please Include the Names of the Parents or Guardian(s):*

  Parent / Guardian	Parent / Guardian

• 5. Nomination Submitted By:*
  First Last
• Title:*
• 6. Facility Administrator:*
  First Last
• Title:*

• PART I

  
  Please Provide the Following Information about Your Nominee:
• 1. Length of Service of Volunteer(s):*
  (years)
• 2. How Frequently does the Volunteer(s) Visit the Facility?*
  (days per week/monthly)
• 3. How Many Hours has the Volunteer(s) Served in the Past 12 Months?*
• 4. How many (if any) volunteers has this nominee recruited for your facility?*
  (about how many)

• PART II

  
  Select the Volunteer(s) Five (5) Primary Tasks and Indicate the Percentage of Time Spent on that Task.
  There does NOT need to be Five Tasks, but there CANNOT be More than Five.
• Primary Tasks*
  • Friendly Visitor (1 to 1)
  • Leads Craft Sessions
  • Leads Exercise Group
  • Provides & Serves Refreshments
  • Leads Group Discussions
  • Transports Residents
  • Provides Personal Services (shopping / grooming)
  • Arranges or Provides Spiritual Guidance or Religious Services
  • Entertainer / Performs for Resident Audiences
  • Makes or Repairs Items for Residents
  • Serves as a Resource to the Activity Director
• Friendly Visitor - % of Time*
• Leads Craft Sessions - % of Time*
• Leads Exercise Group - % of Time*
• Provides & Serves Refreshments - % of Time*
• Leads Group Discussions - % of Time*
• Transports Residents - % of Time*
• Provides Personal Services - % of Time*
• Arranges or Provides Spiritual Guidance - % of Time*
• Entertainer / Performs for Resident Audiences - % of Time*
• Makes or Repairs Items for Residents - % of Time*
• Serves as a Resource to the Activity Director - % of Time*

• PART III

  
  An essay about your volunteer, “I Make A Difference”, is required for submission. Please describe what makes this volunteer or group special. Include ways s/he (or they) help residents reach their own potential while being guided by the theme of "I Make A Difference." (Refer to your volunteer as "this volunteer" or “these volunteers” if it is a group nomination.)
  • Do NOT identify your facility in the essay
  • Do NOT use nursing facility stationery/letterhead
  • Do NOT identify yourself or any facility personnel in the essay
• Upload File:*
  Drop files here or Select files

  Accepted file types: pdf, Max. file size: 10 MB.
  Only PDF files are accepted. Note: If you are having difficulty attaching a file, please FAX both letters to Joanne O'Connor at 518-426-4051. MAX FILE SIZE: 10MB
• 
  If you have any questions, please call Joanne O'Connor at 518-462-4800, Ext. 23.

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