UCLA Nursing: Creating the WOW

Nursing: Creating the WOW

Nursing Excellence in Research and Evidence-Based Practice Submission Form
Did you receive recognition or an award for excellence in research and EBP? Have you published a manuscript or presented at a conference? Did you have an abstract accepted or obtain grant funding for your project/study? We want to hear about your achievements! You will be recognized among your peers and UCLA Health for your professional achievements and strong work in support of research and evidence-based practice in nursing. Please complete the form below.
Today's Date*

MonthDayYear
Date
Name*
Use upper and lowercase. Please do NOT capitalize your name.
E-mail*
Job Title*
Institution*
Unit/Dept.*
Is this achievement submitted as part of an organizational group, committee or council?

Unit Practice CouncilResearch and Innovation CouncilEvidence-Based Practice CouncilProfessional Development CouncilEmpirical Outcomes CouncilCoordinating CouncilNew Knowledge and Innovations CouncilExemplary Professional Practice CouncilStructural Empowerment CouncilTransformational Leadership CouncilOther
1. What was your achievement?*
Title of Abstract*
Type*
Name of Author (provide each author's First Name Last Name, Full Credentials, Institutional affiliations)(Please use upper & lower case. Do NOT capitalize author's name)
Name of Co-author(s) (provide each author's First Name Last Name, Full Credentials, Institutional affiliations)(Please use upper & lower case. Do NOT capitalize author's name)
Conference Name
Conference Location
Conference Date (month/date/year)
Attach a copy of your abstract

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Award Name
Award Recipient(s)
Purpose of Award
Award Sponsor
When will you receive the award?
Check all that apply:

Nominated for awardMerit-based awardIndividual awardTeam-based award
Presentation Title
Primary Presenter's Name (First Name Last Name, Full Credentials)
Name of Co-presenters (Co-authors or Co-investigators) (First Name Last Name, Full Credentials)
Date of Presentation

MonthDayYear
Date
Title of Paper
Journal Name
Publication Status
Year
Volume
Issue
Page number(s)
Title of Grant Proposal
Name of Investigators (provide each investigator's First Name Last Name, Full Credentials, Institutional affiliations)
Name of Grant Award
Name of Funding Agency
Amount Awarded
Purpose of Project/ Study
Other Achievement (please describe)
2. Do you have a photo of yourself and/or your team? If so, please submit below.

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3. Any additional comments you wish to share?
If you have any questions, please contact Dr. Pamela Miller at psmiller@mednet.ucla.edu.
Thank You!
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