Healthcare Dedication Award Nomination Form
Nominate an outstanding healthcare professional for recognition of their dedication and excellence.
Nominee's Full Name
*
First Name
Last Name
Nominee's Job Title/Role
*
Nominee's Department or Unit
*
Nominee's Organization or Hospital
*
Nominee's Email Address
*
example@example.com
Nominee's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Nominator's Full Name
*
First Name
Last Name
Nominator's Email Address
*
example@example.com
Please describe in detail why you believe this nominee deserves the Healthcare Dedication Award. Include specific examples of dedication, compassion, and impact.
*
Nominee Evaluation Criteria
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Rows
Exceptional Patient Care
Teamwork & Collaboration
Innovation in Healthcare
Leadership & Initiative
Community Impact
Excellent
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5
Very Good
6
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8
9
10
Good
11
12
13
14
15
Fair
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18
19
20
Needs Improvement
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25
Supporting Documents (optional)
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Nominator's Signature
*
Submit Nomination
Submit Nomination
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