HYGIEA AWARD NOMINATION FORM
1. Name of Person Nominated ______________________________________ 
Address ______________________________________________________ 
Postal Code _________________ Phone ___________________________ 
2. 	Name of Person Making Nomination ______________________________ 
Address ______________________________________________________ 
Postal Code _________________ Phone ___________________________ Signature _________________________________________ 
3. 	About the Nominee 
How long has the nominee been practicing Infection Prevention & Control? ____________ 

How long has the nominee been an active member of: 
IPAC Canada? _____________           IPAC-CSO? _____________ 

Please describe why this nominee should win the HYGIEA Award (include qualities, characteristics, contributions and/or achievements): 

I ____________________________ (name of nominator) verify that 
_____________________________ (name of nominee) is aware of their nomination for the HYGIEA Award and that they will be required to submit evidence supporting their nomination. 

______________________________________      ______________________________
(signature of nominator) 	(Date)