DUE
NOMINATION FORM
I would like to nominate ____________________________ RN, from the________________________unit/department as a
(first & last name)
(i.e. ICU, PACU, ED, etc)
deserving recipient of The Daisy Award. This registered nurse’s (RN) extraordinary care exemplifies the values that our
patients, their families, and our staff can rely on at Sibley Memorial Hospital, Sibley Renaissance & Grand Oaks Assisted Living
Facility. Please tell us your story by describing how this nurse consistently demonstrates each of the following organizational
values. The award is competitive, so details that create compelling evidence of care and compassion will serve your nominee
well.
Caring and Compassion (Treats everyone with respect, empathy and understanding, anticipates needs, always has a
positive attitude, demonstrates professionalism); Integrity (Follows through, worthy of your trust, demonstrates honesty,
leads by example); Communication (Clearly and effectively communicates with patients and families to understand
important health information.); Excellence (Consistently goes above and beyond to “wow” patients, families and
peers.)
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Thank you for taking time to nominate an extraordinary nurse. Please let us know how to contact you so we may
include you in the celebration should the nurse you nominated be selected.
Your name: ________________________Phone: _________________________ Email: _____________________
Today’s Date __________________________
I am (please check one) RN ___Patient ___ Family/Guest ____ MD ___ Staff ______Volunteer ______
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Manager Acknowledgement
I acknowledge that this nurse is in good standing.____________________________________________________
Signature/Date/ Title
For additional comments, please use the back of this form.
Rev. 01-2016