In collaboration with
NOMINATION FORM
I would like to nominate ___________________________________ from ______________________unit/location as a
deserving recipient of The DAISY Award. This RN’s clinical skill and especially her/his compassionate care exemplify
the kind of nurse that our patients, their families, and our staff recognize as extraordinary. She/he consistently meets all of
the following criteria:
• Demonstrates professionalism in the work place
• Models empathy and demonstrates a caring attitude in all situations
• Job performance exemplifies the mission, vision, and values
• Uses critical thinking skills in the delivery of extraordinary patient care
• Consistent focus on creating an exceptional patient experience
• Demonstrates excellent interpersonal skills with peers and coworkers
• Recognized as outstanding role model in the nursing community
• Demonstrates exemplary service and a commitment to excellence
Please tell your story about the nurse you are nominating that clearly demonstrates he/she meets the criteria for
The DAISY Award:
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Thank you for taking the time to nominate an extraordinary nurse for this award. Please tell us about yourself, so that we
may include you in the celebration of this award should the nurse you nominated is chosen.
Your Name ________________________________Unit/Location ___________________ Phone ___________________
Email ____________________________________ Pager_________________
I am (please check one): RN____ Patient ____ Family/Visitor ____ MD ____ Staff ____ Volunteer ____
Date of nomination ________________________________
Nominations received by the 15th of the month will be considered for the following month’s DAISY Award.
Please mail nomination to: Nursing Administration ℅ Magnet Program Supervisor 1227 East Rusholme St, Davenport IA
52803 or you may just leave it at one of the nurse’s stations.
If you have any questions, please contact: Joan McCann Magnet Program Supervisor at 563-421-7674 or
mccann@genesishealth.com.