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Test Form - Compassion
Nomination Form - Compassion
Your Information:
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Your Name
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Today's Date
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MM slash DD slash YYYY
Your Position Title
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Your State
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Ohio
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Pennsylvania
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Texas
Utah
Washington
Wisconsin
National System Teams
Other
Your email address
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Your Nominee:
Nominee Position (select from dropdown)
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Select:
Leader (Director and Above)
Provider (Physician or APP / APC - e.g., Nurse Practitioner, Physician Assistant, Nurse Midwife)
Staff Member
Team / Department
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Upload a list of email addresses:
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Accepted file types: txt, pdf, xls, doc, docx, Max. file size: 50 MB.
Nominee Name (Search Nominee Formal Last Name)
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Nominee email address
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Facility Name (if working remotely, enter "remote")
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Facility Address (if working remotely, enter "remote")
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Department
Nominee State
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Select:
Arizona
Arkansas
California
Colorado
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Minnesota
Nebraska
Nevada
New Mexico
North Dakota
Ohio
Oregon
Pennsylvania
Tennessee
Texas
Utah
Washington
Wisconsin
National System Teams
Other, please enter below
Other state
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Please do not include any patient identifiable information in the submission.
How does the nominee meet the criteria (below) for their nominated category? (Max: 800 characters)
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Comments
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