HealthImpact DAISY Nurse Leader in Policy AwardNomination Form

HealthImpact DAISY Nurse Leader in Policy Award
Nomination Form

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Eligibility:

Licensed nurses who are employed by DAISY Partner organizations or schools of nursing including students and faculty in the United States.

Nominee may or may not have policy development or oversight as a part of their job description.

Nominee’s policy change must have taken place in the last two years prior to the first day of the application opening for this award.

Individual nurses or nurse-led teams are eligible to apply.

Today's Date

Who Are You Nominating?

Please complete the nomination form addressing all elements in the Nomination Criteria.

About You

First Name

Last Name

Credentials, if any

Title

Email Address

Phone Number

Name of Your Organization

Street Address of Organization:

City

State

Postal Code

About The Nominee

First Name

Last Name

Credentials

Title

Email:

Phone

Mailing Street Address

City

State:

Postal Code

About The Team

Team Name

Team Leader First Name

Team Leader Last Name

Team Leader Credentials

Team Leader Title

Team Leader Email:

Team Leader Phone

Mailing Street Address

City

State:

Postal Code

Where Does The Nominee Work?

Name of DAISY Partner Organization

Street Address of Organization:

City

State

Postal Code

Your Nomination

Please provide detailed information in each section of the nomination below. 200 Words per answer.

Please describe the problem or issue that needed to be addressed. Please focus on how the status quo impeded or did not support compassionate care for patient populations or communities

Describe the policy the nominee created and implemented that impacted compassionate care of patient populations or communities.

Please describe the impact and outcomes of the policy change the nominee created and implemented. Please also give quantitative or qualitative evidence about the impact of the policy change.

How did the policy advance compassionate care of patient populations or communities?

Describe the scope where this policy was implemented

How did your/the nominee’s vision and leadership identify solutions that created change that fostered care and compassion?

Please upload a letter of support from a partner or beneficiary familiar with your contributions to the policy work, on their letterhead.

For questions about this Award please contact Sharon Goldfarb at sharon@healthimpact.org

If you have technical issues with this form, please contact Christina Johnson at ChristinaJohnson@DAISYFoundation.org

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