Tri-State DAISY Award Nomination
***You can now nominate a NURSE or a TEAM FOR THIS AWARD***
Your Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
I am...
*
A Patient
A Family/Visitor
A Registered Nurse
A Physician
Tri-State Memorial Hospital Staff
A Volunteer
Are you nominating a NURSE or a TEAM?
*
Nurse
Team
Name of the NURSE or TEAM you are nominating:
*
Department they are in:
*
Share your story of why your NURSE or TEAM should be honored for the compassion and care they provide their patients everyday, please provide as much detail as possible:
*
Tri-State Marketing & Communications may contact me regarding my DAISY Award testimonial.
Yes
No
Tri-State Marketing & Communications can share my story internally and externally.
Yes
No
If yes, can they include your name?
Yes
No
I would like to be added to Tri-State Memorial Hospital's email list to receive messages regarding hospital changes, updates, service lines, provider information, or general marketing communications.
Yes
No
Submit
Should be Empty: