Veronica Awards — Nomination Form

1.1. Indicate the kind of human/social service organization that the nominee works for (check all that apply):

1.2. Indicate the program or programs in which the nominee works (check all that apply):

1.3. Indicate the nominee’s position(s) – check all that apply:

1.4. Venue – indicate which of these apply:

1.5. Time – indicate which of these apply:

1.6. Are there limitations on contacts/sessions with participants?

1.7. Are there limitations on contacts/sessions with participants?

2.1. What is the size of the nominee’s current caseload?

2.2. As a direct service staff working with a number of program participants, how often does the nominee contact participants on his/her caseload? (Assume a relatively new participant in the first two months of the program)

2.3. At what frequency does the nominee document interactions with participants on his/her caseload?

2.4. Which of the following best describes the duration of the nominee’s case management services?

2.5. How often does the nominee engage in activities outside of traditional “case management” in order to deepen his/her relationship with participants?

2.6. How often does the nominee intentionally revisit progress with program participants by reviewing his/her efforts and participant efforts towards progress on a treatment/progress plan over a given time period?

2.7. Does the nominee have a mechanism in place that allows him/her to know the current status of their entire caseload?

2.8. Which of the following statements best represents the nominee’s philosophy on case management: As a direct service worker, he/she is:

2.9. Respond to the following statement: The nominee modifies his/her own behavior to make sure of using himself/herself appropriately to really meet the program participant where they are.

2.10. Respond to the following statement: The nominee can stay engaged with program participants even when they are upset because the nominee confronts them on hard issues or inappropriate behavior and program participants respond to the higher standards.

2.11. Respond to the following statement: The nominee manages his/her own performance relative to the progress of participants they are working which allows him/her to better understand participant needs and build better relationships with participants.

2.12. Respond to the following statement: The most important indicator of the nominee’s effectiveness as a direct service worker is the strength of the relationship he/she is able to build with them. The nominee actively reflects on and measures the quality of that relationship.

3.1. Discuss the philosophy or clinical/service approach that guides the nominee’s work with participants and give example and give specific examples of the approach in action (15 possible points)

3.2. List the outcomes that the nominee is held accountable to in their work with participants (15 possible points) Indicate whether baseline measures are used and the frequency at which outcomes are measured. Please note the target population served.

3.3. List the activities that the nominee engages in with participants to help them achieve those outcomes (15 possible points) Be specific about the types of activities, their purpose and their frequency.

3.4. Describe what the nominee tracks with each program participant to know they are doing high quality work - i.e. quality indicators, services data (15 possible points):

3.5. Describe what data the nominee tracks with each program participant to know they are successful – i.e., being effective, outcomes data (20 possible points) You may reference short term, intermediate term or long term outcomes or any combination thereof that is tracked through your work.

3.6. Upload non-anecdotal evidence and/or data that draws attention to your effectiveness. Comparative data with other staff serving in the same role is encouraged. While the data could be related to services provided or outcomes achieved by participants, our judging panel will use the following criteria:(20 possible points)

4.1. Please provide three professional references who have worked with the nominee (at least one in a supervisory capacity). Please note: The Superstar Foundation will likely contact all three if you are in serious consideration for an award.